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Acupuncture: A technique for treating certain painful conditions by passing long thin needles through the skin to specific points.

Adjudication: The process used by health plans to determine the amount of payment for a claim.

Allergy Treatment: Treatment for certain conditions which cause an allergic reaction.

Allowable Charge: The maximum fee that a health plan will reimburse a provider for a given service.

Ambulatory Surgery: Surgical procedures performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called Outpatient Surgery.

Ambulatory Services: Services provided in an out-patient setting.

Appeals: A process used by a patient to request the health plan re-consider a previous authorization or claim decision.

Authorization: See Pre-Authorization or Pre-Approval.

Benefit: Payments provided for covered services under the terms of the policy. The benefits may be paid to the insured, or on his behalf, to the medical provider. Benefit design includes the types of benefits offered, limits e.g., number of visits, percentage paid or dollar maximums applied, subscriber responsibility (cost sharing components), subscriber incentives to use network providers.

Benefit Period: The maximum length of time for which benefits will be paid.

Brand Name Drug: A prescription drug that has been patented and is only available through one manufacturer.

Case Management: A program that assists the patient in determining the most-appropriate and cost effective treatment plan. Case management is usually provided to patients who have prolonged, expensive or chronic conditions. The program helps determine the treatment location (hospital, other institution or home) and authorizes payment for such care if it is not covered under the patient's benefit agreement. One Health Plan refers to this program as Care Management.

Certification: See Pre-certification.

Chemotherapy: Treatment of malignant disease by chemical or biological antineoplastic agents.

Chiropractic Care: An alternative medicine therapy administered by a licensed Chiropractor. The Chiropractor adjusts the spine and joints to teat pain and improve general health.

Claim: A request for payment for benefits received or services rendered.

COBRA: Consolidated Omnibus Budget Reconciliation Act of 1985. This Act sets forth certain regulations for continuation of medical care insurance for employees and their dependents.

Coinsurance: An arrangement under which the insured person pays a fixed percentage of the cost of medical care after the deductible has been paid. For example, a health plan might pay 80% of the allowable charge, with the enrollee responsible for the remaining 20%; the 20% amount is then referred to as the coinsurance amount.

Continuation: Continued medical care when a Member is no longer eligible to be covered under the Employers group plan.

Contraception: The prevention of pregnancy.

Contract: A legal agreement between an individual subscriber or an employer group and a health plan that describes the benefits and limitations of the coverage. One subscriber could have two contracts (policies) - one for health and one for dental. Can also be called a Benefit Certificate or Policy.

Contract Holder: See Subscriber.

Conversion Option: The exercise of an option to purchase individual coverage at a negotiated rate by a person who is leaving an employee group, typically at retirement.

Coordination of Benefits (COB): The provision which applies when an enrollee is covered by two health plans at the same time. The provision is designed so that the payments of both plans do not exceed 100% of the covered charges. The provision also designates the order in which the multiple health plans are to pay benefits. Under a COB provision, one plan is determined to be primary and its benefits are applied to the claim first. The unpaid balance is usually paid by the secondary plan to the limit of its responsibility. Benefits are thus "coordinated" between the two health plans.

Co-payment (or co-pay): A way in which the enrollee shares in the cost of health care. The benefit plan requires the enrollee to pay a flat dollar amount per unit of service. An example of a common co-pay is $10 per physician office visit.

Covered Services: Hospital, medical, and other health care services incurred by the enrollee that are entitled to a payment of benefits under a health benefit contract. The term defines the type and amount of expense, which will be considered in the calculation of benefits.

Custodial Care: Care which is provided primarily to meet the personal needs of the patient. Such care includes help in walking, bathing or dressing. It also includes preparing food or special diets, feeding administering medicine or any other care which does not require continuing services of medical-trained personnel.

Customary and Reasonable (C&R): The amount customarily charged for the service by other physicians in the area (often defined as a specific percentile of all charges in the community), and the reasonable cost of services for a given patient after medical review of the case. Also called "Usual, Customary and Reasonable" (UCR).

Day Treatment Center: An outpatient psychiatric facility which is licensed to provide outpatient care and treatment of mental or nervous disorders or substance abuse under the supervision of physicians.

Deductible: An amount the insured person must pay for covered services during a calendar year, January 1 through December 31, before health benefit payments begin.

Dental Care: Care provided by a persons licensed to practice dentistry.

Dependent: Person (spouse or child) other than the subscriber who is covered in the subscriber's benefit certificate. Also called a "Member" or "Beneficiary".

Diagnostic Tests: Tests and procedures ordered by a physician to determine if the patient has a certain condition or disease based upon specific signs or symptoms demonstrated by the patient. Such diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory, pathology services or tests.

Drug Formulary: A list of preferred pharmaceutical products that health plans, working with pharmacists and physicians, have developed to encourage greater efficiency in the dispensing of prescription drugs without sacrificing quality.

Durable Medical Equipment (DME): Mechanical devices, equipment and supplies which enable a person to maintain functional ability. Also called Medical Equipment.

Effective Date: The date on which the coverage of an insurance policy goes into effect at 12:01 a.m.

Emergency Care: Care for patients who experience a sudden onset of symptoms which would lead a prudent layperson to believe that if he or she did not receive immediate treatment it could result in serious jeopardy to his or her health.

Enrollee: An individual who is enrolled and eligible for coverage under a health plan contract. Also called "Member".

Exclusions: Specific conditions or circumstances that are not covered under the benefit agreement. It is very important to consult the benefit contract to understand what services are not covered benefits.

Experimental Procedures: Procedures that are mainly limited to laboratory research.

Expiration Date: The date indicated in an insurance contract as the date coverage expires.

Explanation of Benefits (EOB): A form sent to the enrollee after a claim for payment has been processed by the health plan. The form explains the action taken on that claim. This explanation usually includes the amount paid, the benefits available, reasons for denying payment, or the claims appeal process.

Family practitioner: A licensed physician who has completed a residency in family practice and is board certified in the specialty of family practice.

Formulary: See Drug Formulary.

General practitioner: A licensed physician who has not achieved board certification.

Generic Drug: A drug which is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand drug.

Health Benefit Plan: Is the health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services and a provider network.

Health Maintenance Organization (HMO): A type of health care plan under which the enrollees receive all the medical services they need through a specific group of participating doctors and hospitals.

HMO: See Health Maintenance Organization.

Home Health Care: Health services rendered in the home to an individual who is confined to the home. Such services are provided to aged, disabled, sick or convalescent individuals who do not need institutional care, but who do need nursing services or therapy, medical supplies and special outpatient services.

Home Infusion Therapy: The administration of intravenous drug therapy in the home. Home infusion therapy includes the following services: solutions and pharmaceutical additives; pharmacy compounding and dispensing services; durable medical equipment; ancillary medical supplies; and, nursing services.

Hospice: A facility or service that provides care for the terminally ill patient and who provides support to the family. The care, primarily for pain control and symptom relief, can be provided in the home or in an inpatient setting.

Hospital: An institution whose primary function is to provide inpatient services, diagnostic and therapeutic, for a variety of medical conditions, both surgical and non surgical. In addition, most hospitals provide some outpatient services, particularly emergency care.

I.D. Card/Identification Card: A card issued to a subscriber and possibly his/her dependents, which allows the subscriber to identify himself or his covered dependents to a provider for health care services. The card is subsequently used by the provider to determine benefit levels and to prepare the billing statement.

Idemnity: A tradition health insurance plan that reimburses for medical services provided to patients based on bills submitted after the services are rendered. Also know as fee-for-service plans. These plans generally do not have a specific provider network.

Immunizations: The process of creating immunity to a specific disease in an individual through administration of vaccinations.

In-Network: Refers to the use of providers who participate in the health plan's provider network. Many benefit plans encourage enrollees to use participating (in-network) providers to reduce the enrollee's out-of-pocket expense.

Infertility: Term used to describe the inability to conceive or an inability to carry a pregnancy to a live birth after a year or more of regular sexual relations without the use of contraception. Also includes the presence of a condition recognized by a physician as the cause of infertility.

Infusion Therapy: Treatment accomplished by placing therapeutic agents into the vein, including intravenous feeding. Such therapy also includes enteral nutrition which is the delivery of nutrients into the gastrointestinal tract by tube.

Inpatient: Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.

Investigational Procedures
A drug, device, medical treatment or procedure which:

Our Medical Director may, in his/her sole discretion, determine that a drug, device, medical treatment or procedure which is deemed experimental or investigational under the above criteria, should nonetheless not be deemed experimental or investigational.

Managed Care: Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires pre-authorization of certain services.

Maternity Care: Prenatal, childbirth and postnatal care. Coverage for you and your baby, if dependent coverage is elected, includes a Hospital stay of 48 hours following a normal vaginal delivery and 96 hours following a C-section. The 48/96 hours begin following delivery of the last newborn in case of multiple-births. When delivery takes place outside a hospital, the 48/96 hours begin at the time of inpatient admission. The Hospital stay may be less than the 48-hour or 96-hour minimum if a decision for early discharge is made by the attending Doctor in consultation with the mother. Pre-authorization is not required for the 48/96-hour Hospital stay. However, authorization is needed for a longer stay than as described above.

Medical Equipment (DME): Non-disposable medical equipment appropriate for use within a Member's home. Covered equipment must be able to withstand repeated use and be used to treat an Illness. Replacement of equipment is covered only when required as a result of normal usage.

Medical Management: Before a Member is hospitalized or has surgery outside the Doctor's office, the Member's Doctor must call Medical Management for pre-treatment authorization. This telephone number is on the ID card.

Medically Necessary: Any services and supplies provided for the diagnosis and treatment of a specific illness, injury or condition must be:

ONE may require proof in writing satisfactory to it that any type of treatment, service or supply received is Medically Necessary. Medical necessity will be determined solely by ONE. The fact that a Physician may prescribe, order, recommend or approve a service does not, in itself, make such service or supply Medically Necessary.

Medical necessity does not include any:

Member: An individual or dependent who is enrolled in and covered by a managed health care plan. Also called Enrollee or Beneficiary.

Mental Health/Behavioral Health: Conditions that affect thinking and the ability to figure things out and that affect perception, mood and behavior. Such disorders are recognized primarily by symptoms or signs that appear as distortions of normal thinking, or distortions of the way things are perceived (seeing or hearing things that are not there.) Disorders can also be recognized by moodiness, sudden or extreme changes in mood, depression, highly agitated or unusual behavior.

Network: The doctors, clinics, hospitals and other medical providers that a health plan contracts with to provide health care to its members. Members are generally limited to network providers for full coverage of their health costs.

Network Provider: Physicians and Hospitals located within a defined geographical area and who have agreed to a set fee schedule. Network providers are neither agents nor employees of our company, nor is our company, or any employee of our company, an agent or employee of the Network providers.

The service area of ONE means the geographical areas, designated by ONE and approved by the appropriate regulatory body in your state, within which ONE provides services. Providers under contract with ONE are independent contractors. Network providers are neither agents nor employees of ONE, nor is ONE, or any employee of ONE, an agent or employee of network providers.

Non-Participating Provider: A medical provider who has not contracted with a health plan as a participating provider.

Occupational Therapy: Treatment to restore a physically disabled person's ability to perform activities such as walking, eating, drinking, dressing, toileting, and bathing.

Out of Network: The use of health care providers who have not contracted with the health plan to provide services. HMO members are generally not covered for out-of-network services except in emergency situations. Members enrolled in preferred provider organizations (PPO) and point-of-service (POS) coverages can go out-of-network, but will pay some additional costs.

Out-of-Pocket Maximum: Refers to the maximum amount that an enrollee will have to pay for expenses covered under the health plan. The maximum is a sum of all paid deductible and co-payment or coinsurance amounts.

Outpatient: A patient who is receiving care at a hospital, physician office or other health facility without being admitted to the facility for an overnight stay. The term "ambulatory" is often used to describe outpatient care.

Outpatient Surgery: Surgical procedures performed that do not require an overnight stay in the hospital or ambulatory surgery facility. Such surgery can be performed in the hospital, a surgery center, or physician office.

Partial Day Treatment: A program offered by appropriately-licensed psychiatric facilities that includes either a day or evening treatment program for mental health or substance abuse. Such care is an alternative to inpatient treatment.

Participating Provider: A physician, hospital, pharmacy, laboratory, or other appropriately licensed facility or provider of health care services or supplies, that has entered into an agreement with a managed care entity to provide services or supplies to a patient enrolled in a health benefit plan.

PCP: See Primary Care Physician

Physical Therapy: Treatment involving physical movement to relieve pain, restore function and prevent disability following disease, injury, or loss of limb.

Point of Service (POS): A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do.

Pre Authorization: A procedure used to review and assess the medical necessity and appropriateness of elective hospital admissions and non emergency outpatient services before the services are provided.

Preventive Care: Periodic physical exams by a Doctor for a Member who is at least eight days of age. This includes x-ray and lab services if part of the annual physical exam, necessary immunizations and booster shots. For a Member over the age of two, benefits are payable for one exam per year.
The Plan covers an annual pelvic exam, Pap smear and mammogram.

Pre-Certification: Before a Member is hospitalized or has surgery outside the Doctor's office, the Member's Doctor must call Medical Management for pre-treatment authorization. This telephone number is on the ID card.

Medical Management will determine:

Pre-Existing Condition: A health condition (other than a pregnancy) or medical problem that was diagnosed or treated before enrollment in a new health plan or insurance policy. Some pre-existing conditions may be excluded from coverage.

Preferred Provider Organization (PPO): A type of health benefit plan designed to give enrollees incentives to use health care providers designated as "preferred providers", but that also give substantial coverage for services received from other health care providers. PPO plans can also be distinguished from HMO plans by the ability of PPO members to see any specialty physician without referral from a PCP.

Prescription: A written order or refill notice issued by a licensed medical profession for drugs which are only available through a pharmacy.

Primary Care Physician (PCP): A doctor selected by the enrollee to be the first physician contacted for any medical problem. The doctor acts as the patient's regular physician and coordinates any other care the patient needs, such as a visit to a specialist or hospitalization.

Prior Authorization: The process of obtaining advanced approval of coverage for a health care service or medication. Also called Pre-Certification.

Prosthetic Devices: A device which replaces all or portion of a part of the human body. These devices are necessary because a part of the body is permanently damaged, is absent or is malfunctioning.

Provider: A licensed health care facility, program, agency, physician or health professional that delivers health care services.

Provider Network: That set of providers contracted with a health plan to provide services to the enrollees. In the case of a "fee-for-service" or non-network health plan, the provider network is generally all licensed providers of covered services.

Radiation Therapy: Treatment of disease by x-ray, radium, cobalt or high energy particle sources.

Reasonable and Customary: The fee usually charged by other providers in the same geographical area for these services and supplies.

Referral: A recommendation by a physician that an enrollee receive care from a specialty physician or facility.

Respiratory Therapy: Treatment of illness or disease that is accomplished by introducing dry or moist gases into the lungs.

Second Opinion: The voluntary option or mandatory requirement to visit another physician or surgeon regarding diagnosis, course of treatment or having specific types of elective surgery performed.

Service Area: The geographic area in which a health plan is prepared to deliver health care through a contracted network of participating providers.

Skilled Nursing Facility (SNF): A licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services.

Speech Therapy: Treatment of the correction of a speech impairment which resulted from birth, or from disease, injury, or prior medical treatment.

Subscriber: The individual in whose name a contract is issued or the employee covered under an employer's group health contract. The subscriber can enroll dependents under family coverage.

Substance Abuse/Chemical Dependency: Prolonged use of drugs or alcohol that cause physical and mental impairment.

Utilization Management: See Medical Management.

Utilization Review: See Medical Management.

Usual, Customary and Reasonable: A "usual" charge is the amount that is most consistently charged by an individual physician for a given service. A "customary" charge is the amount that falls within a specified range of usual charges for a given service billed by most physicians with similar training and experience within a given geographic area. A "reasonable" charge is a charge that meets the Usual and Customary criteria, or is otherwise reasonable in light of the complexity of treatment of the particular case. Under an UCR Program, the payment is the lowest of the actual billed charge, the physician's usual charge or the area customary charge for any given covered service.

Urgent Care: Services received for an unexpected illness or injury that is not life threatening but requires immediate outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering or sever pain, such as a high fever.

Well Baby/Well Child Care: Routine care, testing, checkups and immunizations for a generally healthy child from birth through the age of six.