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Glossary
of Healthcare Terms |
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Making the most of your health plan means understanding it. Please review
these commonly used Managed Care terms. If you have any further questions,
please Contact
Us.
Click on the word to read the definition, or scroll down to read the entire list.
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Balance
Billing |
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The practice of a provider billing a patient for all charges not paid
for by the insurance plan, even if those charges are above the plan's
Usual, Customary, or Reasonable (UCR) charges.
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Board-Certified |
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A physician who has passed an examination given by a medical specialty board.
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Board-Eligible |
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A physician who has graduated from an approved medical school and is
eligible to take a specialty board examination.
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Capitation |
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A method of paying for medical services on a per-person rather than a
per-procedure basis. Under capitation, an HMO pays a doctor a fixed amount
each month to take care of HMO members, regardless of how much or how
little care each member needs.
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Center
of Excellence |
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A network of health care facilities selected for specific services based
on criteria such as specialties, experience, outcomes and efficiency. For
example, through an organ transplant managed care program, members can
select benefits through a specific network of medical centers.
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Copayment |
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A fee charged to HMO members for each office visit or pharmacy
prescription filled to offset costs of paperwork and administration.
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Credentialing |
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The process of reviewing a provider’s licenses, certifications,
insurance, malpractice history, etc. Mercy Health Plans credentials every
provider in its network.
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Deductible |
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A fixed amount of health care dollars of which a person must pay 100%
before his or her health benefits begin. Most indemnity plans feature a
$200 to $500 deductible and then pay up to 100% of money spent for covered
services above this level.
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Fee-For-Service |
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A traditional method of paying for medical care by reimbursing the
doctor (or patient) for the cost of care provided.
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Formulary |
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The panel of drugs chosen by a hospital, Managed Care Organization or
other health plan that is used to treat patients. Drugs outside of the
formulary are only used in rare, specific circumstances.
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Generic
Drug |
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A chemically equivalent copy designed from a brand-name drug whose
patent has expired. Typically less expensive and sold under the common
name for the drug, not the brand name.
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Health
Maintenance Organization |
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A type of health plan that provides health care in return for set
monthly payments. Most HMOs provide care through a network of doctors,
hospitals and other medical professionals that members must use in order
to be covered for care. For the patient, it means reduced out-of-pocket
costs (i.e., no deductible), no paperwork (i.e., insurance forms), and
only a small copayment for each office visit or prescription.
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Indemnity
Plan |
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Traditional health insurance that usually covers a percentage of the
cost of care (often 80%) after the consumer pays an annual deductible.
Patients with indemnity coverage can choose any doctor or hospital for
their care.
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Integrated
Delivery System |
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A group of doctors, hospitals and other providers who work together to
deliver a broad range of health care services.
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Managed
Care Organization |
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An umbrella term for health plans that provide health care in return for
a set monthly payment and coordinate care through a network of physicians
and hospitals. Health maintenance organizations and point-of-service plans
are managed care organizations.
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Network |
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A group of doctors, hospitals and other providers who contract with a
managed care plan to provide care for its members.
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Nonparticipating
Provider |
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A health care provider who has not contracted with the carrier or health
plan to be a participating provider of health care.
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Nurse
Practitioner |
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A registered nurse who has advanced skills in the assessment of physical
and psychosocial health status of individuals, families, and groups in a
variety of settings through medical history taking and physical examinations.
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Out-Of-Pocket-Costs |
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The share of health service payments made by the enrollee.
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Point-Of-Service-Plan |
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A type of managed care plan that allows members to choose to receive
services either from the participating HMO providers, or from providers
outside the HMO’s network. The highest benefits are paid for care
received within the network; members pay deductibles and a percentage of
the cost of care from non-network providers.
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Preventative
Care |
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Health care emphasizing priorities for prevention, early detection and
early treatment of conditions, generally including routine physical
examination, immunization, and well-person care.
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Primary
Care Physician |
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A physician, usually an internist, pediatrician, or family physician,
devoted to the general medical care of patients. Most HMOs require members
to choose a primary care physician, who is then expected to provide or
authorize all care for that patient.
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Provider |
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A health care professional or facility that provides care, such as a
doctor, specialist, nurse, health center, physical therapist, lab,
hospital, etc.
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Referral |
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A formal process that authorizes an HMO member to get care from a
specialist or hospital. Most HMOs require patients to get a referral from
their primary care doctor before seeing a specialist.
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Urgent
Care Center |
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A medical facility where ambulatory patents can be treated on a walk-in
basis, without an appointment, and receive immediate, non-emergency care.
The urgent care center may be open 24 hours a day; patients calling an HMO
after-hours with urgent, but not emergent clinical problems are often
referred to these facilities.
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Wellness |
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A health care process that fosters awareness and attitudes toward health
lifestyles so that individuals can make informed choices to achieve
optimum physical and mental health.
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