Want more information about the terms and initials we use to describe our products and services? Click on the alphabet below to navigate through our definition of terms. You can also scroll through the entire list.
A
Accreditation
An evaluative process in which a healthcare organization undergoes an
examination of its operating procedures to determine whether the procedures
meet designated criteria as defined by the accrediting body, and to ensure
that the organization meets a specified level of quality.
Active Contract
A member that currently has coverage with Empire.
Actual Charge
The amount a physician or other practitioner actually bills a patient for a
medical service or procedure.
Acupuncture
A traditional Chinese medical practice of insertion of fine needles into
specific exterior body locations to relieve pain, to induce surgical
anesthesia, and for therapeutic purposes.
Acute Illness
A physical condition or illness that begins abruptly and requires medical care
or restricted activity for a short period of time (usually 3 months or less).
Adjudication
The process by which a claim is paid or denied based on eligibility and
contract determination.
Admission
Formal acceptance as an inpatient by an institution, hospital or healthcare
facility.
Admitting Physician
The physician responsible for admission of a patient to a hospital or other
inpatient health facility
Advance Directive
Any spoken or written decision with your instructions and preferences for
medical treatment. If you sign an advance directive, your family and your
doctor will know who to talk to about your care or what kinds of treatment you
want or don't want if you are too sick or incompetent to decide. If you become
unable to make decisions about your health care treatment, your family may not
be able to make decisions for you unless you sign a health care proxy
directive.
Aggregate Family Deductible
Allergy Treatment
Allowable Charge
Allowance
Allowed Amount
Ambulatory Care
Ambulatory Care Facility
Ambulatory Surgery
Ancillary Services
Appeal(s)
Assignment
Attending Physician
Authorization
Authorized Services
Aggregate Family Deductible
A deductible which is met when two or more family members' charges are added
together to meet a family deductible.
Allergy Treatment
The treatment of the allergic patient may include identifying the offending
agent by means of various testing methods. Once the agent is identified,
treatment is provided by avoidance, medication, or immunotherapy.
Allowable Charge
The maximum fee that a health plan will reimburse a provider for a given
service.
Allowance
The amount an individual provider/member is entitled to receive for a certain
service.
Allowed Amount
The maximum reimbursement the member's health policy allows for a specific
service in or out of network. This amount may be:
-a fee negotiated with participating providers
-a customary charge based on the amount -charged by most providers in the member's area
-an allowance established by law
-an amount set on a Fee Schedule of Allowance
-a fee negotiated with participating providers
-a customary charge based on the amount -charged by most providers in the member's area
-an allowance established by law
-an amount set on a Fee Schedule of Allowance
Ambulatory Care
All types of health services that are provided on an outpatient basis.
Ambulatory Care Facility
A medical care center that provides a wide range of healthcare services,
including preventive care, acute care, surgery and outpatient care in a
centralized facility.
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.
Ancillary Services
Auxiliary or supplemental services (i.e. diagnostic services, physical
therapy, medications) used to support diagnosis and treatment of a patient's
condition.
Annual out-of-pocket Coinsurance Maximum
The most you will have to pay in out-of-pocket costs for coinsurance on
covered services during a calendar year. Charges in excess of the allowed
amount (see definition) are not applied toward this maximum.
Appeal(s)
A process used by a provider or member to request the health plan reconsider a
previous authorization or claim decision.
Assignment
An agreement in which a patient assigns to another party, usually a physician
or hospital, the right to receive payment from a public or private insurance
program for the service the patient has received.
Attending Physician
Physician primarily responsible for the care of a patient during
hospitalization.
Authorization
See 'Pre-Authorization'
Authorized Services
See 'Precertified Services'.
B
Balance Billing
Billing a member or other responsible party for the difference between the
insurer's payment and the actual charge.
BCBSA
See 'Blue Cross and Blue Shield Association'.
Behavioral Healthcare
The provision of mental health and substance abuse services.
Benefit(s)
Services available to a member as defined in the contract. 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), and subscriber incentives to use network providers.
Benefit Period
The way that Medicare measures the use of hospital and skilled nursing
facility services. A benefit period begins the day a member enters a
hospital or skilled nursing facility and ends when hospital or skilled
nursing care has not been received for 60 consecutive days. A new benefit
period begins when the member enters the hospital after the previous benefit
period has ended. A new inpatient hospital deductible is payable for each
benefit period.
Benefits Exhausted
When the maximum number of visits for a specific service is reached, further
benefits will not be considered.
Billed Fee
The amount charged by a provider for a specific service.
Billing Address
The address to which a billing statement will be sent.
Blue Cross and Blue Shield Association (BCBSA)
A corporation formed by the BlueCross BlueShield plans to establish national
standards and act as a national coordinating agency. The association
headquarters are in Chicago, IL.
BlueCard Access
A toll-free 1-800 number, 1-800-810-BLUE, Customer Service Representatives
and members can use to locate providers in another BlueCross BlueShield
Plan's area. This number is useful when Customer Service Representatives
need to refer the patient to a physician or healthcare facility in another
geographic location.
BlueCard Worldwide Program
A program that allows BlueCross BlueShield members traveling or living
abroad to receive inpatient and outpatient institutional and professional
services from participating health care providers worldwide. The program
also allows members of foreign BlueCross BlueShield Plans to access U.S.
BCBS provider networks.
BlueCard Managed Care/POS Program
A health benefit program that covers employees of national companies. The
highest level of benefits is received when members obtain services from
their primary care provider/group and/or comply with referral and/or
authorization requirements for care. Substantial benefits are still provided
when members obtain care from any eligible provider without referral or
authorization, according to the contract terms.
BlueCard PPO Program
A national program that offers members traveling or living outside of their
BlueCross BlueShield Plan's area the PPO level of benefits when they obtain
services from a physician or hospital designated as a BlueCard PPO provider.
Board Certification
A process by which a physician who has been tested for proficiency in a
medical specialty or subspecialty, by a medical specialty board, has passed
those tests and therefore been certified as proficient in that medical
specialty.
Board Eligible
Denoting a physician who has completed the educational requirements
necessary for eligibility to take the specialty board examinations.
Brand Name Drug
A prescription drug that has been patented and is only available through one
manufacturer.
C
Carrier
An insurance company that either administers insurance or self-insures.
Carryover (4th Quarter) Deductible
An option sometimes contained in a health insurance contract where
deductible amounts incurred under a member's contract in the last three
months of the year are applied towards the deductible of the next
calendar/benefit year.
Carve Out Contract
Case Management
A program that assists the patient in determining the most-appropriate and
cost effective treatment plan including coordinating and monitoring the
care with the ultimate goal of achieving the optimum healthcare outcome.
Certificate of Coverage (Certificate)
A plan booklet that describes the benefits, features, and services of a
health plan.
Certification
A process in which an individual, an institution, or an educational
program is evaluated and recognized as meeting certain predetermined
standards. Certification usually applies toward individuals and
accreditation usually applies toward institutions.
Charges not Covered
Provider changes that exceed the insurer's payment for services, or
services not covered by your health policy
Chemotherapy
Treatment of malignant disease by chemical or biological antinoeplastic
agents.
Chiropractic Care
An alternative medicine therapy administered by a licensed Chiropractor.
The chiropractor's specialty is the relief, correction and prevention of
musculo-skeletal problems of the spine, peripheral joints and related
areas through manipulation.
Chronic Care
A pattern of medical care that focuses on long-term care with chronic
diseases or conditions.
Claim
An itemized statement of healthcare services and their costs provided by
hospital, physician's office or other healthcare facility. Claims are
submitted to the insurer or managed care plan by either the plan member or
the provider for payment of the costs incurred.
Claim Form
An application for payment of benefits under a healthcare plan.
Clinical Decisions
A clinical decision is a decision about your medical treatment.
Clinical Issues
A clinical issue is information relating to your health.
Clinical Professionals
Doctors, nurses and other healthcare professionals are clinical
professionals.
Clinical Reviews
A clinical review is when a clinical professional reviews information
about your health.
COB
See 'Coordination Of Benefits'.
COBRA
See 'Consolidated Omnibus Budget Reconciliation Act'.
Coinsurance
Cost-sharing requirement that the insured pay a designated percentage of
the allowed amount for covered services.
Coinsurance Maximum
The most you will have to pay in out-of-pocket costs for coinsurance on
covered services during a calendar year.
Complaint
A verbal or written inquiry from a member or provider expressing
dissatisfaction with any aspect of their care, coverage or specifically
with Empire.
Concurrent Care
Medical care rendered within the aftercare period of surgery, by other
than the surgeon, and the condition is different from the one treated
surgically.
Consolidated Omnibus Budget Reconciliation Act (COBRA)
A federal act which requires each group's health plan to allow employees
and certain dependents to continue their group coverage for a stated
period of time following a qualifying event that causes the loss of group
health coverage. Qualifying events include reduced work hours, death, or
divorce of a covered employee and termination of employment.
Consultation
Services rendered by a physician whose opinion or advice is requested by
another physician for further evaluation or management of the patient.
Continuation of Coverage
Procedure by which individuals transferring from one insurance plan to
another are allowed uninterrupted coverage from the date of original
enrollment.
Contraception
The process by which pregnancy is prevented by either barring conception
of an embryo or the implantation of it within the uterine wall.
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.
Contract Holder
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.
Conversion
A change of a customer's contractual status involving the method of
payment of subscription charges and possible types of coverage. For
example, a member may transfer from a group policy to direct payment
coverage upon termination of employment.
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)
The fixed dollar amount that your policy requires you to pay as your share
of the cost of certain services each time you receive care.
Cost Sharing
The provision of a health insurance policy that requires insured
individuals to pay some portion of the covered medical expenses. Several
forms of cost sharing are deductible, copayment and coinsurance.
Covered Services
The services for which Empire provides benefits under the terms of your
contract.
Custodial Care
Maintenance care of a patient which is designed to assist the patient in
daily living and not primarily provided for the treatment of an illness,
disease or condition. Custodial care includes but is not limited to help
in walking, bathing and feeding.
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).
Customary Charges
The fees most providers charge for a certain procedure. These charges are
determined based on charge data collected from providers in a geographical
area at a certain time period.
D
Date of Service
The date on which a service was rendered.
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
Dollar amount that an insured person or family must pay each year before
an insurer will assume any liability for the remaining cost of covered
services.
Denial of Benefits
A rejection of an entire claim or part of a claim.
Dental Care
The treatment of the oral cavity.
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 Service
A test or procedure rendered because of specific symptoms which is
directed toward the determination of the definite condition or disease.
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, or pathology services.
Direct Payment
Individual subscribers who are billed and pay premiums directly to the
insurer.
Discharge Date
Date the patient left the hospital.
Disease Management
A coordinated system of preventive, diagnostic and therapeutic measures
intended to provide cost-effective, quality healthcare for a patient
population who have or are at risk for a specific chronic illness or
medical condition.
Domestic Partner
Such partners must be 18 years of age or older, unmarried and not
related by marriage or blood in a way that would bar marriage or living
together in a lifetime relationship that is financially interdependent.
The partners must be each other's sole domestic partner and must have
been involved in the domestic partnership for a period no less than six
months.
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. Our Drug Formulary is available for
download. Requires
Adobe Acrobat reader.
Durable Medical Equipment
Mechanical devices, equipment and supplies which enable a person to
maintain functional ability. Also called Medical Equipment.
E
Effective Date
The date on which the coverage of an insurance policy goes into effect
at 12:01 a.m.
Elective Surgery
Surgery for a condition that is not considered an emergency.
Eligibility
A determination of whether or not a person meets the requirements to
participate in the plan.
Eligibility Period
The period of time a group stipulates must elapse before a group
member becomes eligible for benefits.
Emergency
An emergency is a medical or behavioral condition of which the onset
is sudden. It manifests itself by symptoms of such severity that a
prudent lay person with an average knowledge of medicine and health
could reasonably expect that the absence of immediate medical
attention would result in: placing the health of the afflicted person
in serious jeopardy; placing the health of an individual with a
behavioral health condition or others in serious jeopardy; causing
serious impairment of the individual's bodily functions; causing
serious dysfunction of any bodily organ or part; causing serious
disfigurement of the afflicted individual.
Emergency Care
Care for patients with severe or life-threatening conditions that
require immediate intervention.
Employee Retirement Income Security Act (ERISA)
This law, enacted in 1974, applies to employee benefit plans,
including health benefits. The law is designed to protect the interest
of employees and requires full disclosure to the employees of their
rights under the plan.
Enrollee
An individual who is enrolled and eligible for coverage under a health
plan contract. Also called "Member".
EOB
See 'Explanation Of Benefits'.
EOMB
See 'Explanation Of Medicare Benefits'.
EPO
See 'Exclusive Provider Organization'.
ERISA
See 'Employee Retirement Income Security Act'.
Exclusion
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.
Exclusive Provider Organization (EPO)
A healthcare benefit arrangement that is similar to a preferred
provider organization in administration, structure and operation but
which does not cover out-of-network care.
Experimental Procedures
Procedures that are mainly limited to laboratory research.
Expiration Date
The date indicated in an insurance contract as the date coverage
expires at 12:00 midnight.
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.
Explanation of Medicare Benefits (EOMB)
A statement detailing the amount of benefits paid or denied for
services reported on a member's claim for services under the Medicare
program.
Extended Care Facility
An institution devoted to providing medical, nursing or custodial care
for an individual over a prolonged period of time as during the course
of a chronic disease or during the rehabilitation phase after an acute
illness.
Extended Medical
Coverage that supplements basic hospital and surgical medical coverage
designed to cover a broad scope of extra hospital and medical costs.
These costs may include provider home and office visits, prosthetics,
ambulance services and hospitalization longer than the time allotted
by the regular hospital plan. These benefits are usually subject to a
deductible, coinsurance, lifetime maximum and out-of-pocket limits.
F
Facility
A facility is a hospital, ambulatory surgical facility, birthing
center, dialysis center, rehabilitation facility, skilled nursing
facility or other provider certified under New York Public Health
Law. A hospice is a facility. An institutional provider of mental
health substance abuse treatment operating under New York Mental
Hygiene Law and/or approved by the Office of Alcoholism and
Substance Abuse Services is a facility.
Family Deductible
The dollar amount of the member's health benefit coverage that must
be met each calendar year before payment can be made on claims.
There is a maximum out-of-pocket amount that will satisfy the family
deductible. Once that deductible is reached, all claims are then
paid at 100% of allowable charges.
Fee For Service Payment
A payment method in which the insurer will reimburse the member or
provider directly for each covered medical expense.
Fee Schedule
The fee determined by the insurer to be acceptable for a procedure
or service that the physician agrees to accept as payment in full.
Formulary
See 'Drug Formulary'.
Full Time Student
A dependent enrolled at an accredited institution of learning. The
student's principal residence, when not away at school, must be the
same as their parents.
G
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 name drug.
Grievance
A request to change an adverse determination that was based on
administrative policies, procedures or guidelines.
Group Contract
Agreement to provide health insurance made with an employer that
covers a group of persons identified by their relation to the group.
Group Number
Group specific identification number.
H
Health Benefit Plan
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 Insurance Portability and Accountability Act (HIPAA)
A federal act that protects people who change jobs, are
self-employed or who have pre-existing medical conditions. HIPAA
standardizes an approach to the continuation of healthcare
benefits for individuals and members of small group health plans
and establishes parity between the benefits extended to these
individuals and those benefits offered to employees in large group
plans. The act also contains provisions designed to ensure that
prospective or current enrollees in a group health plan are not
discriminated against based on health status.
Health Maintenance Organization (HMO)
An organization which provides comprehensive healthcare coverage
to its members through a network of doctors, hospitals and other
healthcare providers.
Healthcare Financing Administration (HCFA)
The Governmental agency responsible for administering the Medicare
and Medicaid programs.
Healthcare Provider
A professionally licensed individual, facility or entity giving
health-related care to patients. Physicians, hospitals, skilled
nursing facilities, pharmacies, chiropractors, nurses,
nurse-midwives, physical therapists, speech pathologist,
laboratories, etc. are providers. All network providers are
healthcare providers, but not all providers are network providers.
See network provider and non-network provider.
Hearing Services
Diagnostic audiological testing that includes a wide variety of
qualitative modalities not only to detect hearing loss, but also
to define the nature and extent of a given deficit.
HMO
See 'Health Maintenance Organization'.
Home Health Care
Healthcare services rendered to a member in their home in lieu of
confinement in a hospital or skilled nursing facility. Care must
be under the supervision of a registered professional nurse. This
type of care may include physical, occupation or speech therapy,
medical supplies and medication prescribed by a doctor.
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.
Hospital Affiliation
The hospital in which the provider is associated.
I
ICU
See 'Intensive Care Unit'.
I.D. Card (Identification Card)
A card 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.
Identification Card
A card 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.
Identification Number
A unique number which identifies the member's enrollment with
Empire.
Immunizations
There are two types of acquired immunizations; Active
immunization: naturally acquired during an infectious disease or
artificially by vaccination with dead or living organisms.
Passive immunization: can be naturally acquired during when
maternal antibodies are passed to the child via placenta, in the
milk or artificially by administering immune sera containing
antibodies obtained from animals or humans.
In Process
A claim that has been received by Empire, but has not been
finalized.
Inactive Contract
A member that does not have coverage with Empire.
Indemnity
A tradition health insurance plan that reimburses for services
provided to patients based on bills submitted after the services are
rendered. Also known as fee-for-service plans.
These plans generally do not have a specific provider network.
Indemnity Benefits
A type of health insurance product characterized by reimbursement on
a fee for service basis, freedom of choice in selecting providers
and fewer managed care rules and regulations.
Independent Practice Association (IPA)
An organization comprised of individual physicians or physicians in
group practices that contracts with the insurer on behalf of its
member physicians to provide healthcare services.
Individual Deductible
The dollar amount of the member's health benefit coverage that must
be met each calendar year before becoming eligible for benefits for
the remaining cost of covered services. There is a maximum
out-of-pocket amount that will satisfy the individual deductible.
Once that deductible is reached, all claims are then paid at 100% of
allowable charges.
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 that is the delivery of nutrients into the
gastrointestinal tract by tube.
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.
In-Network Provider/Supplier
A healthcare provider such as a physician, skilled nursing facility,
home health agency, laboratory etc, who has an agreement with Empire
to provide covered services to members.
Inpatient
Service provided after the patient is admitted to the hospital.
Inpatient stays are those lasting 24 hours or more.
Inpatient Care
Treatment that is provided to a patient who stays overnight (more
than 23 hours) in a hospital or other facility.
Insured
The individual or organization protected in case of loss under the
terms of an insurance policy.
Intensive Care Unit (ICU)
A specialized unit in the hospital which concentrates on seriously
ill patients needing constant nursing care and observation.
Investigational Procedures
The first step in determining eligibility of a medical procedure for
coverage is evaluating its health effects This process is known as
'Technology Assessment'. Procedures/Services failing this process
will be considered "Experimental/Investigational"
IPA
See 'Independent Practice Association'.
Itemized Bill
A bill from a provider that itemizes all charges for services
rendered needed to process for payment.
J
No J terms
K
No K terms
L
Lifetime Maximum
The maximum amount of benefits your policy will pay for covered
expenses over the course of your lifetime.
Limitation
Specific circumstances or services listed in the contract for which
benefits will be limited.
M
Mail Order Pharmacy Program
A program that offers drugs ordered and delivered through the mail
to plan members usually providing a three-month supply of the
prescribed drug.
Mailing Address
The address designated by the member for all correspondence
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.
Mandated Benefit
A benefit that must be included in the basic contract as a result of
government legislation.
Maternity Care
Maternity care includes all services provided to a pregnant female
including evaluation and management (ante and postpartum care),
diagnostic testing, delivery (c - section or vaginal), and various
miscellaneous services.
Medicaid
A jointly funded federal and state program that provides hospital
and medical coverage to the low income population and certain aged
and disabled individuals.
Medical Card
The card that is presented to doctors and medical facilities showing
the person as a member of Empire for medical health insurance
benefits.
Medical Care
Professional services rendered by a physician for the treatment or
diagnosis of an illness or injury.
Medical Equipment (DME)
Goods, implements, prosthetics, etc., that are prescribed for
patient care, usually in an outpatient setting. Examples of such
equipment include hospital beds, wheelchairs, and walkers.
Medically Necessary
Empire regards services, supplies or equipment provided by a
hospital or covered provider of health services as medically
necessary if Empire determines that they are:
-Consistent with the symptoms or diagnosis and treatment of the patient's condition, illness or injury;
-in accordance with standards of good medical practice;
-not solely for the convenience of the patient, the family, or the provider;
-not primarily custodial; and the most appropriate level of service for the patient's safety. The fact that a covered provider may have prescribed, recommended, or approved a service, supply, or equipment does not, in itself, make it medically necessary.
-Consistent with the symptoms or diagnosis and treatment of the patient's condition, illness or injury;
-in accordance with standards of good medical practice;
-not solely for the convenience of the patient, the family, or the provider;
-not primarily custodial; and the most appropriate level of service for the patient's safety. The fact that a covered provider may have prescribed, recommended, or approved a service, supply, or equipment does not, in itself, make it medically necessary.
Medicare
A nationwide insurance program for the disabled and people aged 65
and over, created by the 1965 amendments to the Social Security Act
and operated under the provisions of the Act. It consists of two
separate but coordinated programs, Part A and Part B.
Medicare Carve Out Contract
A contract that stipulates the Medicare-eligible members of a group
receive benefits at least equal to benefits received by non-Medicare
group members. Members are reimbursed up to the group's contract
limitations, reduced by what Medicare paid or would have paid if the
member were Medicare-eligible and Medicare were the primary
coverage.
Medicare Part A
This is part of the Medicare law providing benefits for
hospitalization, extended care and nursing home care to Medicare
beneficiaries with no premium payment for qualified individuals.
Medicare Part B
This is part of the Medicare law providing medical surgical benefits
for Medicare beneficiaries for a modest premium.
Medicare Supplement Contract
Health insurance policy designed to supplement Medicare, beginning
at the point Medicare coverage ceases for a particular service. Also
referred to as a Medigap policy.
Member
A person, including eligible covered dependents, that has coverage
with Empire.
Member ID Number
A unique number that identifies the person as a member with Empire.
Many times the member's ID is the insured's social security number.
Member Services
The department responsible for helping members with problems, and
questions.
Mental Health/Behavioral Health
Conditions that affect thinking and the ability to figure things out
that affect perception, mood and behavior.
Message Center
A secure area on the website which contains e-messages for the
member.
N
NCQA (National Committee for Quality Assurance)
A not-for-profit organization that performs quality-orientated
accreditation reviews of HMOs and similar types of managed care
plans.
Need Info
An indicator on a claim that identifies that additional information
is required before the claim can be finalized.
Network
The group of physicians, hospital, and other medial care providers
that a specific plan has contracted with to deliver medical services
to its members.
Network Provider
A doctor, hospital or other healthcare provider who has entered into
an agreement with Empire to provide healthcare services to members
for a negotiated rate of reimbursement.
No Fault
A law in several states including New York State requiring all
registered motor vehicles to be covered by personal injury
protection insurance. Under this law, a person's own motor vehicle
insurance company pays for expenses relating to an accident
regardless of who caused the accident.
Non-Participating Hospital/Facility
A hospital/facility that does not have a participation agreement
with Empire BlueCross BlueShield or another BlueCross and/or
BlueShield plan to provide hospital/facility services to persons
covered under Empire.
Non-Participating Provider
A healthcare provider such as a physician, skilled nursing facility,
home health agency, laboratory etc, who does not have an agreement
with the Empire to provide covered services to members.
O
Occupational Therapy
Treatment to restore a physically disabled person's ability to
perform activities such as walking, eating, drinking, dressing,
toileting, and bathing (activities of daily living).
Omnibus Budget Reconciliation Act (OBRA)
A federal act which set guidelines for Medicare and insurers.
Open Enrollment
A limited time period in which enrollment applications for coverage
elections or changes may be made.
Operating Area
Empire operates in the following 28 eastern New York State counties:
Albany, Bronx, Clinton, Columbia, Delaware, Dutchess, Essex, Fulton,
Greene, Kings, Montgomery, Nassau, New York, Orange, Putnam, Queens,
Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Schoharie,
Suffolk, Sullivan, Ulster, Warren, Washington, Westchester.
Out-of-Network
The use of health care providers who have not contracted with the
health plan to provide services. Depending on your contract, out of
network services may not be covered. Please refer to your contract
for specific benefit coverage.
Out-of-Network Benefits
Reimbursement for covered services provided by out-of-network
providers and suppliers. Out-of-network benefits are generally
subject to a deductible and coinsurance and, therefore, have higher
out-of-pocket costs. Depending on your contract, out of network
services may not be covered. Please refer to your contract for
specific benefit coverage.
Out-of-Pocket Maximum
Dollar amount set by the insurer that limits the amount members have
to pay out of their own pocket for particular covered healthcare
services during a specified time period.
Outpatient Care
Treatment that is provided to a patient who is able to return home
after care without an overnight stay in a hospital or other
inpatient facility
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.
P
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 Hospital/Facility
A hospital or facility that is part of Empire's provider network and
has signed an agreement to provide covered services to its members.
Participating Provider
A healthcare provider such as a physician, skilled nursing facility,
home health agency, laboratory etc, who has an agreement with Empire
to provide covered services to its members.
Past Plan
The plan with which the member previously had health insurance.
Patient Bill of Rights
Refers to the Consumer Bill of Rights and Responsibilities, a report
prepared by the President's Advisory Commission on Consumer
Protection and Quality in the Healthcare Industry in an effort to
ensure the security of patient information, promote healthcare
quality, and improve the availability of healthcare treatment and
services.
Pharmacy Card
The member's identification card which also identifies the pharmacy
coverage and copay requirements.
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.
Plan Benefit Maximum
Dollar amount set by the insurer that limits the amount members have
to pay out of their own pocket for particular covered healthcare
services during a specified time period.
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.
POS
See 'Point Of Service'.
PPO
See 'Preferred Provider Organization'.
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.
Pre-certification
See 'Pre-Authorization'
Precertified Services
Services that must be coordinated and approved by Empire's medical
or behavioral healthcare management programs to be fully covered by
your plan. Examples may include: planned inpatient surgeries, and
medical tests such as MRIs and MRAs. To avoid a reduction or denial
of benefits, members must precertify.
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 healthcare benefit arrangement designed to supply services at a
lower cost to use in-network healthcare providers (who contract with
the PPO at a discount). The PPO also provides coverage for services
rendered by healthcare providers who are not part of the PPO network
at a higher out-of-pocket cost to the member.
Premium
A prepaid payment or series of payments made to a health plan by
purchasers and often plan members for health insurance coverage.
Prescription
A written order or refill notice issued by a licensed medical
professional for drugs which are only available through a pharmacy.
Prescription Drugs
Drugs and medications that are required by law to be dispensed by
written prescriptions from a licensed physician.
Preventive Care
Comprehensive care emphasizing priorities for prevention, early
detection, and early treatment of conditions, and generally
including routine physical examinations and immunization.
Primary Care Physician (PCP)
A PCP is a family physician – family practitioner, general
practitioner, internist or pediatrician - who is responsible for
delivering or coordinating care.
Primary Carrier
A term used when administering the COB program, which defines the
insurance company called upon first to consider payment.
Prior Authorization
The process of obtaining advanced approval of coverage for a health
care service or medication. Also called Pre-Authorization.
Professional Provider Number
An identification number that identifies a doctor or provider with
the insurance company.
Prosthetic Device
A device which replaces all or portion of a part of the human body.
Provider
A licensed health care facility, program, agency, physician or
health professional that delivers health care services.
Provider Network
A set of providers contracted with a health plan to provide services
to the enrollees.
Q
No Q terms
R
Radiation Therapy
Treatment of disease by x-ray, radium, cobalt or high energy
particle sources.
Reasonable and Customary
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).
Referral
A recommendation by a physician that an enrollee receive care from a
specialty physician or facility.
Referral Care
Care you receive from a network provider (for example, a specialist)
other than your PCP. However, your PCP is required to provide the
referral.
Respiratory Therapy
Treatment of illness or disease that is accomplished by introducing
dry or moist gases into the lungs.
Retrospective Review
A review done after services are completed (usually as part of a
claim or appeal), that ensures that the care given was medically
necessary.
Rider
A provision added to a contract whereby the scope of its coverage is
increased or decreased.
S
Same-Day Surgery
Same-day, ambulatory or outpatient surgery is surgery that does not
require overnight stay in a hospital.
SARA
See 'Systematic Analysis Review and Assistance program'.
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. Refer to your
contract for specific guidelines.
Secondary Coverage
A term used when administering Coordination of Benefits that defines
the insurance company called upon to consider second payment for
services.
Self Insurance
Practice of an individual, group of individuals, employer or
organization assuming complete responsibility for the losses that
might be insured against such as healthcare expenses. In effect,
self insured groups have no real insurance against potential losses
and instead maintain a fund out of which is paid the contingent
liability subject to self-insurance.
Service Area
The geographic area in which a health plan is prepared to deliver
health care through a contracted network of participating providers.
Short-term Care
Refers to treatment or care intended to improve or restore a
member's functioning within a reasonable period of time. Short-term
care is expected to produce a positive result, not maintain
functioning or prevent decline.
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.
Specialized Services
Services provided by specialists, not by your PCP. For example, an
allergist (who treats allergies) or a radiologist (who uses x-rays
for diagnosis and treatment) are specialists.
Specialty Care Center
A facility accredited or designated by an agency or the state or by
a voluntary national health organization as having special expertise
in treating a specified condition or disease.
Specialty Care Coordinator
The specialty care coordinator is a network specialist with
expertise in a disabling, degenerative, or life-threatening
condition, who manages the treatment of a member with such a
condition and shares authority for treatment options with the PCP.
In some cases, the specialty care coordinator will initiate an
Out-of-Network referral.
Speech Therapy
Treatment of the correction of a speech impairment which resulted
from birth, disease, injury, or prior medical treatment
Stop Loss
Dollar amount set by the insurer that limits the amount members have
to pay out of their own pocket for particular covered healthcare
services during a specified time period.
Subscriber
The individual in whose name a contract is issued. The employee
covered under an employer's group health contract. The subscriber
can enroll dependents under family coverage.
Substance Abuse/Chemical Dependency
The use of one or more drugs for purposes other than those for which
they are prescribed or recommended.
Systematic Analysis Review and Assistance Program (SARA)
SARA is a feature of Empire's Early Risk Management program. It is
an innovative approach to help physicians and our members optimize
opportunities for early detection and intervention. Using a
specialized computer program, it analyzes existing medical, lab,
pharmacy and hospital claims to identify patients at risk for
potentially serious medical conditions such as heart attacks and
strokes.
T
Third Party Address
Person and address designated by a Medicare Supplement customer to
receive final notice of payment due on their account. (Under NY
State law, a person with Medicare Supplement insurance may designate
another person (third party) to receive a final notice of payment
due. In the event we have not received payment and coverage is in
danger of being canceled, a copy of the final notice will be sent to
that person.
Third Party Payer
Any organization that pays or insures health or medical expenses on
behalf of beneficiaries or recipients such as Empire, commercial
insurance companies, Medicare and Medicaid. The individual generally
pays a premium for such coverage in all private and some public
programs.
Treatment Maximums
Maximum number of treatments or visits for certain conditions.
Maximums for in-network and out-of-network services are combined.
For example, if the plan has a limit of 30 visits on a covered
expense, you would reach the limit if you had 17 visits in-network
and 13 visits out-of-network.
U
UCR
See 'Usual Customary and Reasonable charge'.
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.
Usual Customary and Reasonable Charge (UCR)
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).
Utilization Management
The process of evaluating and determining the coverage for and the
appropriateness of medical care services, as well as providing any
needed assistance to clinician or patient in cooperation with other
parties, to ensure appropriate use of resources. Utilization
Management includes prior authorization, concurrent review,
retrospective review, discharge planning and case management.
Utilization Review
A formal evaluation (prospective, concurrent or retrospective) of
the coverage, medical necessity, efficiency or appropriateness of
health services and treatment plans.
V
No V Terms
W
Waiting Period
A period of time an individual must wait either to become eligible
for insurance coverage or to become eligible for a given benefit
after overall coverage has commenced.
Waiver of Liability
A provision whereby a provider of service may be relieved from
liability for a disallowed claim.
Worker's Compensation
Insurance carried by employers to cover occupation-related injuries
or conditions incurred by the employees.
X