Term
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Definition
| Automated Clearing House – The process of payment of an insurance premium through pre-authorized automated withdrawals from a member’s bank account. |
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Term
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Definition
| Processing a claim through a series of edits to determine proper payment |
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Term
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Definition
| Non-plan providers who have an agreement to supply certain services to DHP members at an in plan location. |
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Term
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Definition
| A state licensed salesperson that solicits insurance on behalf of an insurance company and receives commission for his/her sales. |
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Term
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Definition
| The maximum fee a third party will reimburse a provider for a given service. |
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Term
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Definition
| Medical Services provided on an outpatient basis. Services may include diagnosis, treatment, surgery, and rehabilitation. |
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Term
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Definition
| Additional health care services performed |
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Term
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Definition
| A state program designed to provide health insurance for uninsured or underinsured working families. |
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Term
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Definition
| Method of payment for health services in which a physician or hospital is paid a fixed amount for each enrollee regardless of the actual number or nature of services provided to each person. |
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Term
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Definition
| Planned approach to manage service or treatment to an individual with a serious medical problem |
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Term
Certificate of Coverage
(Member Certificate) |
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Definition
| A formal document listing health plan benefits |
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Term
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Definition
| Information submitted by a provider or covered person to establish that medical services were provided to a covered person, from which processing for payment to the provider or covered person is made. |
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Term
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Definition
| Portion of incurred medical expenses, usually a fixed percentage, that the patient must pay out of pocket. |
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Term
| Consolidated Omnibus Budget Reconciliation Act (COBRA) |
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Definition
| A federal law that requires employers to offer continued health insurance coverage to employees who have had their health insurance terminated. |
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Term
| Coordination of Benefits (COB) |
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Definition
| Members covered by two or more insurances. |
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Term
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Definition
| A fee charged to HMO members for specific services listed in their Schedule of Benefits. |
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Term
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Definition
| Review and documentation of the credentials of professional providers. |
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Term
| Current Procedural Terminology (CPT) |
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Definition
| Standard set of five digit codes describing medical services delivered that are used for billing by professional providers. |
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Term
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Definition
| A specific dollar amount that a member is responsible for paying prior to any services being covered under their health plan |
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Term
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Definition
| The identification of a disease or condition through examination |
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Term
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Definition
| A rate agreed to between the provider and the health plan that is lower than the provider’s customary fee. |
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Term
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Definition
| An annual event that allows currently insured employees to change health insurance carriers. Dual Choice is available when the employer offers various insurance plans. The employee must apply for the same type of coverage they currently have (single, family, etc). If an employee waives coverage when first eligible and want to enroll later during Dual Choice, the employee would be subject to health underwriting. |
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Term
| Durable Medical Equipment (DME) |
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Definition
| Equipment that can be repeatedly used, generally is not useful to a person in the absence of illness or injury, and is appropriate for use at home. |
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Term
| Electronic Claims Transmission (ECT) |
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Definition
| The process of transmitting provider claims for payment via an agreed upon electronic media, instead of transmitting paper claim forms. |
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Term
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Definition
| An employee who meets the eligibility requirement specified in the group contract to qualify for coverage. |
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Term
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Definition
| Life threatening condition requiring immediate medical attention |
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Term
| Explanation of Benefits (EOB) |
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Definition
| Explanation to a member from a health insurance company explaining how a claim was processed |
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Term
| Explanation of Medicare Benefits (EOMB) |
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Definition
| Explanation from Medicare explaining their payment on a claim |
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Term
| Explanation of Payment (EOP) |
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Definition
| Explanation to a provider from the insurance company as how the claim was paid. |
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Term
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Definition
| of payment for provider services based on each visit or service rendered. |
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Term
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Definition
| Maximum dollar or unit allowances for health services that apply under a specific contract. |
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Term
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Definition
| List of prescription drugs covered by your insurance |
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Term
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Definition
| A body of subscribers eligible for group insurance by virtue of some common identifying attribute |
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Term
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Definition
| A form developed by the health Care Financing Administration to be used by health care providers to bill health insurance companies. National Form used by clinics to bill services. |
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Term
| HCFA Common Procedural Coding System (HCPCS) |
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Definition
| A listing of services, procedures, and supplies offered by physicians and other providers |
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Term
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Definition
| Continuum of maintenance, custodial, and health services for the chronically ill, disabled, or mentally impaired. |
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Term
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Definition
| Term used to describe the coordination of financing and provision of health care to produce high-quality health care for the lowest possible cost. |
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Term
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Definition
| State programs with federal matching funds for public health assistance to persons, regardless of age, whose income and resources are insufficient to pay for health care. |
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Term
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Definition
| Medications delivered by injection. If given in an office setting, will apply to medical benefits. If given at home, will apply to pharmacy benefits. These do not appear on the formulary. |
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Term
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Definition
| Federally sponsored program under the Social Security Act that provides hospital benefits, supplementary medical care, and catastrophic coverage to persons 65 years of age and older and some younger persons who are covered under Social Security benefits. |
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Term
| Medicare Supplement Policy |
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Definition
| - A plan sold to individuals enrolled in Medicare. It is designed to cover the Medicare deductibles and coinsurance. |
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Term
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Definition
| A provider who has not contracted with the health plan or carrier |
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Term
| Office of Commissioner of Insurance (OCI) |
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Definition
| An office that operates as part of the State of Wisconsin government that regulates all insurance companies, agents & brokers to ensure they comply with Wisconsin laws & regulations. |
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Term
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Definition
| An annual event allowing employees to enroll in a plan or change plans without restrictions. |
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Term
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Definition
| Amount owed by the member for covered services. |
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Term
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Definition
| Members can choose to use in plan or out of plan providers for each service. |
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Term
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Definition
| Providers who have signed a participating agreement with DHP & whose name appears in the DHP Provider Directory |
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Term
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Definition
| Any medical symptom that has been diagnosed or treated within a specified period before the member’s effective date of coverage under the group contract |
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Term
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Definition
| Periodic payment to keep an insurance policy in force |
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Term
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Definition
| Health care emphasizing priorities for prevention, early detection and early treatment of conditions |
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Term
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Definition
| Primary care physician-directed transfer of a patient to a specialty physician or specialty care |
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Term
| Schedule of Benefits (SOB) |
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Definition
| The SOB gives detailed benefits on the plan selected. |
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Term
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Definition
| Determining if someone other than DHP is liable for coverage of care |
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Term
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Definition
| The person who has the health plan policy in their name, whether the policy is bought just for the individual or the entire family |
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Term
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Definition
| Standard health insurance claim form primarily used by hospitals to bill for services, procedures, & supplies rendered. |
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Term
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Definition
| Care that is required sooner than a regular office visit |
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Term
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Definition
| Liability insurance requiring certain employers to pay benefits & furnish medical care to employees for on-the-job injuries & to pay benefits to dependents of employees killed in occupational accidents. |
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Term
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Definition
| Authorization to see an non plan provider, inpatient hospital stays, or other services or pharmaceuticals that require an authorization before use. |
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