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Member Glossary of Terms

 

Accreditation – Accreditation programs give an official authorization or approval to an organization against a set of industry-derived standards related to quality and performance.

Acute Care – Treatment for a short-term or episodic illness or health problem.

Allowable Charge – The maximum fee a third party will reimburse a provider for a given service.

Ambulatory Care – Health services that do not require hospitalization of a patient, such as those delivered at a physician’s office, clinic, medical center, or outpatient facility.

Appeal – A formal request by a practitioner, enrollee or their authorized representative for reconsideration of a decision with the goal of finding a mutually acceptable solution.  

Approved Charge – The maximum fee a health plan will pay in a given area for a covered service.

Body Mass Index (BMI) – A statistical formula using a person’s weight and height to measure their body fat and health risks.

Case Management – A shared process between the enrollee and family, case management team, and involved health care providers.  This process includes assessing, planning, implementing, coordinating, monitoring and evaluating options and services in order to meet an enrollee’s and his/her family’s needs. 

Claim – Information submitted by a provider or covered person to establish that medical services were provided from which processing for payment to the provider or covered person is made.

Coinsurance – The portion of covered health care costs for which the covered person has a financial responsibility, usually according to a fixed percentage, until the out-of-pocket maximum is met.

ConnectCare – MidMichigan Health Network’s managed health care products with medical management services intended as a partnership between patients and their providers to provide access and to coordinate quality health care in appropriate settings.

Copayment – A cost-sharing arrangement in which a covered person pays a specified charge for a specific service.  Also known as copay.

Date of Service – The date on which health care services were provided to the covered person.

Deductible – Amount eligible expense a person must pay each year before his or her health benefits begin.

Denial – Refusal of a request for care or services.

Explanation of Benefits (EOB) – The statement sent to covered persons by their health plan listing services provided, amount billed, and payment made.

Health Insurance Portability and Accountability Act (HIPAA) – Enacted in 1996 to create a set of requirements that allow for insurance portability, and guaranteed issue of all health insurance products to small groups. HIPAA was amended in 2002 to establish minimum Federal privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers.

Inpatient – An individual who had been admitted to a hospital as a registered bed patient and is receiving services under the direction of a physician for at least 24 hours.

Medical Necessity – The determination that an intervention recommended by a treating practitioner is  the most appropriate available supply or level of service for the individual in question, considering potential benefits and harms to the individual; known to be effective in improving health outcomes.  For interventions that are not yet in widespread use, an organization determines effectiveness based on scientific evidence.  For established interventions, an organization determines effectiveness based on scientific evidence, professional standards and expert opinion.

Network - ("Participating" or "In-network") The doctors, clinics, health centers, medical group practices, hospitals, and other health care providers that a Preferred Provider Organization or other managed care network plan has selected and contracted with to care for its members.

Out of Network (OON) – Coverage for treatment obtained by a covered person outside the network service area. 

Outpatient – A person who receives health care services without being admitted to a hospital.

Preauthorization – The process of obtaining prior approval as to the appropriateness of targeted services to ensure that the services follow accepted standards of care, are deemed medically necessary, and take place at the most appropriate level of service. 

Precertification – The process of obtaining prior approval as to the appropriateness of routine services in order to notify the concurrent review system that a case will be occurring, and ensure that care takes place in the most appropriate setting.

Preferred Provider Organization (PPO) – An organization that contracts with independent providers at a discount for services.

Protected Health Information (PHI) – Health information, such as medical records, claims, and other administrative data, that identifies or can lead to identification on an individual. 

Provider – An institution or organization that provides services for the enrollees.  

Summary Plan Description – A description of the entire benefits package available to an employee as required to be given to persons covered by self-funded plans. 

Third Party Administrator (TPA) – An independent person or corporate entity that administers group benefits, claims, and administration for a self-insured company or group. 

Utilization Management (UM) – The process of evaluating and determining the coverage for and the appropriateness of medical services, as well as providing any needed assistance to clinicians or enrollees in cooperation with other parties to ensure the appropriate use of available resources.   A critical aspect of UM is attention to quality, which denotes adherence to standards and a commitment to improvement. 

Utilization Review (UR) – A formal evaluation of the coverage, medical necessity, efficiency or appropriateness of health care services and treatment plans. 

Certified by NCQA since 2007

NCQA Certified Utilization Management"Achieving Utilization Management Certification from NCQA demonstrates that ConnectCare has the systems, process and personnel in place to conduct utilization management in accordance with the strictest quality standards." -- Margaret E. O'Kane, President, NCQA

NCQA has reviewed and certified ConnectCare's Utilization Management functions only. For complete details on the scope of this review, visit www.ncqa.org.