Glossary of Health Care Terms

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Glossary of Health Care Terms

Access: A patient's ability to obtain medical care as determined by factors such as the availability of medical services, their acceptability to the patient, the location of health care facilities, transportation, hours of operation, and cost of care.
Ambulatory Care: Health services delivered on an outpatient basis (a patient makes the trip to the doctor's office or surgical center without an overnight stay).
Ancillary Care: Additional healthcare services performed, such as lab work and x-rays.
Authorization: The approval from the managed care organization for care from a non-network provider, or as specified in the member handbook.
Behavioral Health Care: Treatment of mental health and/or substance abuse disorders.
Benefit Coverage: Specific health services provided to plan members as described in the employer group or subscriber contract, which could include primary care, hospitalization, outpatient care, ambulatory or emergency services.
Benefit Year: The annual period for which an employer group purchases its health benefits program.
Calendar Year: The period beginning January 1 of any year through December 31 of the same year.
Case Management: A process where a covered person with specific healthcare needs is identified and a plan is designed and used to achieve the best patient outcome in the most cost-effective manner.
Claim: Information submitted by a provider or covered member to establish that medical services were provided to a covered plan enrollee from which processing for payment to the provider or covered member is made.
Coinsurance: The percentage of the costs of medical services paid by the subscriber.
Copayment: A nominal fee paid by the subscriber for each office visit or pharmacy prescription filled.
Credentialing: Examination of a healthcare provider's qualifications to determine admittance into a participating provider network or receipt of clinical privileges at a hospital.
Deductible: A fixed dollar amount that a subscriber contributes in payment for medical services during a specific period. (Example-any medical expenses incurred during the year above an annual deductible of $100 would then be covered by insurance.)
Dependent: An individual who receives health insurance through a spouse, parent, or other family member.
Disease Management: A philosophy toward the treatment of the patient with an illness (usually chronic in nature) that seeks to prevent recurrence of symptoms, maintain high quality of life, and prevent future need for medical resources by using a comprehensive approach to health care. Pharmaceutical care, continuous quality improvement, practice guidelines, and care management all play key roles in this effort, which should result in decreased health care costs as well.
Effective Date: The date which insurance coverage begins
Eligible Employee: An employee who meets the requirements specified within the employer group contract to qualify for health benefit coverage.
Employee Contribution: The portion of the insurance premium paid by the employee for their health benefit coverage.
Enrollment: The process by which a health plan signs up individuals or groups as subscribers.
Explanation of Benefits (EOB): The statement sent to a member listing the services provided, amount paid, and eligible expenses paid by the insurance company.
Fee-for-Service: Traditional provider reimbursement in which the physician is paid according to the service performed (system used by conventional indemnity insurers).
Formulary: The list of drugs chosen by hospital, managed care organization, or other health plan that is used to treat patients.
Generic Drug: A chemically equivalent copy designed from a brand-name drug whose patent has expired (typically less expensive and sold under the common name).
Grievance Procedures: The process by which a subscriber expresses dissatisfaction in writing with the HMO and seeks recourse.
Group: A body of subscribers eligible for insurance by virtue of some common identifying attribute, such as a common employer, or a membership in a union, association, or other organization.
Group Contract: The application and addenda, signed by both the health plan and the enrolling contract unit, which constitutes the agreement regarding the benefits, exclusions, and other conditions between the health plan and the enrolling unit. (A contract is usually limited to a 12-month period and subject to renewal thereafter.)
Health Insurance: A contractual relationship whereby an insurance company (the insurer) agrees to reimburse the insured for health care costs in exchange for a premium. The contract (policy) generally stipulates the type of health care benefits covered as well as costs to be reimbursed.
HMO-Health Maintenance Organization: A form of health insurance in which members prepay a premium for health services, and which generally includes a defined set of services made available through a defined panel of physicians for enrollees at a preset price. (For the member, it means reduced out-of-pocket costs and limited paperwork.)
Hospital Affiliation: A contractual agreement between an HMO and one or more hospitals whereby the participating hospital(s) provide the hospital care benefits offered by the plan.
Individual Contract: The remittance agreement between an insurer and an individual which specifies rates, performance covenants, relationship among the parties, schedule of benefits and other pertinent conditions. A contract is usually limited to a 12-month period and subject to renewal thereafter.
Inpatient: A patient admitted to a hospital and who is receiving services under the direction of a physician for at least 24 hours.
LOS: Length of Stay
Medical Management: An integrated working relationship between the managed care organization and the healthcare providers whereby medical protocols are established for the delivery of quality health care and the most positive clinical outcomes.
Member: One who is enrolled within a prepaid health program for health services through an individual or group contract (includes both subscribers and their enrolled dependents).
Network: A defined group of providers, typically linked through contractual arrangements, which supplies a full range of primary and acute healthcare services.
Out-of-Network: Any group of non-participating practitioners that are not contracted with a HMO to provide services to their members
Out-of-Pocket Expense: Portion of health services or health costs that must be paid for by the plan member, including deductibles, co-payments, and coinsurance.
Outpatient: Services provided outside of a hospital, skilled nursing facility, or other healthcare institution at the time services are accessed.
Premium: A fixed periodic payment for insurance coverage. Also referred to as rate.
Preventive Care: Healthcare emphasizing priorities for prevention, early detection, and early treatment of conditions, generally including routine physical examination, immunization and well-person care.
Primary Care Physician (PCP): Healthcare provided by general practitioners, family practice, internal medicine, obstetricians and pediatricians usually in a clinic setting.
Prior Written VHP Authorization (PWVA): The approval from the managed care organization for care from a non-network provider, or as specified in the member handbook.
Provider: Any supplier of healthcare services, i.e., physicians, practitioner, pharmacies, hospitals, or other healthcare facilities that provide services to members.
Schedule of Benefits: A definition of healthcare benefits specifically identified as available to the enrolled member which includes the limit or degree of service that member is entitled to receive based upon his or her contract with a health plan or insurer.
Specialty Care: Healthcare services provided by medical specialists who generally do not have the first contact with patients, but instead are referred to them by primary care and family physicians.
Subscriber: The eligible person in whose name a healthcare service contract or insurance policy is held either individually or as a family including dependents.
Usual, Customary, and Reasonable: Commonly charged fees for health services in a certain geographic area.
Utilization Review: The process of evaluating the necessity, appropriateness and efficiency of the use of medical services, procedures and facilities.


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