|
|
|
| Glossary of Frequently used Health Insurance Terms : |
| A B C D E F G H I J K L M N O P Q R S T U V W X Y Z |
Accreditation
An evaluative process in which a healthcare organization undergoes an examination of its policies and 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.
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
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.
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.
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.
Appeal(s)
A process used by a provider or member to request the health plan reconsider a previous adverse determination.
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 or Authorized
Services which have been approved for payment based on a review of MCBL policies. |
| A B C D E F G H I J K L M N O P Q R S T U V W X Y Z |
Balance Billing
Billing a member or other responsible party for the difference between the insurer's payment and the actual charge.
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 dirham maximums applied), and subscriber responsibility (cost sharing components).
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.
Brand Name Drug
A prescription drug that has been patented and is only available through one manufacturer. |
| A B C D E F G H I J K L M N O P Q R S T U V W X Y Z |
Carrier
An insurance company that either administers insurance or self-insures.
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.
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 Rationale
A statement that provides additional clarification of the clinical basis for a non-certification determination. The clinical rationale should relate the non-certification determination to the patient's condition or treatment plan, and should supply a sufficient basis for a decision to pursue an appeal.
Clinical Reviews
A clinical review is when a clinical professional reviews information about your health.
Clinical Review Criteria
The written screens, decision rules, medical protocols, or guidelines used by the utilization management organization as an element in the evaluation of medical necessity and appropriateness of requested admissions, procedures, and services under the auspices of the applicable health benefit plan.
 
Co-insurance 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 or coverage .
 
Consultation
Services rendered by a physician whose opinion or advice is requested by another physician for further evaluation or management of the patient.
Consumer
An individual person who is the direct or indirect recipient of the services of the organization. Depending on the context, consumers may be identified by different names, such as "member," enrollee," "beneficiary," "patient," etc. A consumer relationship may exist even in cases where there is not a direct relationship between the consumer and the organization.
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 contract holder can enroll dependents under family coverage.
Contractor
A business entity that performs delegated functions on behalf of the insurer or managed care organization.
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.
Coordinated Care
Coordinated Care is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefit plan; sometimes called "utilization review."
Coordination of Benefits (COB)
The provision which applies when an enrollee is covered by more than one health plan at the same time. The provision is designed so that the payments of the 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 and tertiary plan, if applicable, to the limit of their responsibility. Benefits are thus "coordinated" among the health plans.
Co-Payment (Co-Pay Charge)
The fixed dollar amount members must pay for certain covered services. It is paid to a Network Provider at the time the service is rendered.
Cost Sharing
A comprehensive term for the deductible, co-payment, and co-insurance provisions in your plan.
Covered Services
The services for which MCBL provides benefits under the terms of your contract.
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. |
| A B C D E F G H I J K L M N O P Q R S T U V W X Y Z |
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
A portion of eligible expenses that an individual or family must pay during a calendar year before MCBL will begin to pay benefits for covered services.
Delegation
The process by which the organization permits another entity to perform functions and assume responsibilities covered under these standards on behalf of the organization, while the organization retains final authority to provide oversight to the delegate.
Denial of Benefits
A rejection of an entire claim or part of a claim.
Dental Care
The treatment of the oral cavity.
Dependent
An individual other than the subscriber who is eligible to receive health care services under the subscriber's Certificate of Insurance. Generally, dependents are limited to the subscriber's spouse and eligible children.
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 or managed care organization.
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.
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. |
| A B C D E F G H I J K L M N O P Q R S T U V W X Y Z |
Facility
A facility is a hospital, clinic, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under Ministry of Health, Abu Dhabi and/ Department of Health Dubai.
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.
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.
|
| A B C D E F G H I J K L M N O P Q R S T U V W X Y Z |
Generic Drug
A drug which is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Ministry of Health 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
The Group Contract is the Agreement MCBL has with your group to provide health insurance.
Grievance Procedure
A complaint process whereby you, or your duly authorized representative, may seek review of benefit determinations or other determinations made by MCBL relating to your health plan.
|
| A B C D E F G H I J K L M N O P Q R S T U V W X Y Z |
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.
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.
Health Professional
An individual who: (1) has undergone formal training in a health care field; (2) holds an associate or higher degree in a health care field, or holds a state license or state certificate in a health care field; and (3) has professional experience in providing direct patient care.
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.
|
| A B C D E F G H I J K L M N O P Q R S T U V W X Y Z |
License
A license or permit (or equivalent) to practice medicine or a health profession that is 1) issued by any state or jurisdiction in the United States; and 2) required for the performance of job functions.
Lifetime Maximum
The maximum accumulated payments MCBL will make for covered services rendered to a covered person per lifetime, or the maximum number of days/visits available to a covered person per lifetime for a particular service or services.
Limitation
Specific circumstances or services listed in the contract for which benefits will be limited.
|
| A B C D E F G H I J K L M N O P Q R S T U V W X Y Z |
| Mail Order Pharmacy Program
A program that offers drugs ordered and delivered through the mail to plan members.
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.
Medical Care
Professional services rendered by a physician for the treatment or diagnosis of an illness or injury.
Medical Director
A doctor of medicine or doctor of osteopathic medicine who is duly licensed to practice medicine and who is an employee of, or party to a contract with, a utilization management organization, and who has responsibility for clinical oversight of the utilization management organization's utilization management, credentialing, quality management, and other clinical functions.
Member
The term "member" refers to you, the subscriber, to whom a Certificate has been issued. The term "member" also refers to any members of your family who are eligible for coverage under your Certificate as a dependent.
Member ID Number
A unique number that identifies the person as a member with MCBL.
 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.
|
| A B C D E F G H I J K L M N O P Q R S T U V W X Y Z |
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 MCBLl to provide healthcare services to members for a negotiated rate of reimbursement.
Non-Certification
A determination by a utilization management organization that an admission, extension of stay, or other health care service has been reviewed and, based on the information provided, does not meet the clinical requirements for medical necessity, appropriateness, level of care, or effectiveness under the auspices of the applicable health benefit plan.
Non-Participating Hospital/Facility
A hospital/facility that does not have a participation agreement with MCBL or another MCBLl
plan to provide hospital/facility services to persons covered under MCBL.
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 MCBL to provide covered services to members. |
| A B C D E F G H I J K L M N O P Q R S T U V W X Y Z |
| Participating Hospital/Facility
A hospital or facility that is part of MCBLl's provider network and has signed an agreement to provide covered services to its members.
Participating Provider/Network Provider
A participating provider is a physician or other Provider who has agreed to accept MCBL's scheduled or negotiated rates as payment in full or covered services (except for any applicable co-payments, co-insurance or deductibles).
 Physical Therapy
Treatment involving physical movement to relieve pain, restore function and prevent disability following disease, injury, or loss of limb.
Pre-Authorization or Pre-Certification
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-Authorized or Pre-Certified Services
Services that must be coordinated and approved by MCBL's medical department. Examples may include: planned inpatient surgeries, and medical tests such as MRIs and MRAs.
Pre-Existing Condition
A pre-existing condition is any disease, symptom or condition that was present on the first day of coverage and for which medical advice or treatment was recommended or received during the six-month period prior to the enrollment date.
Preferred Provider
A Preferred Provider is any physician or other Provider who has agreed with MCBL to accept MCBL's payment as payment in full for covered services and to adhere to all applicable MCBL managed care protocols.
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.
Prior Authorization
The process of obtaining advanced approval of coverage for a health care service or medication. Also called Pre-Authorization or Pre-Certification.
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 Provider is a medical practitioner or covered facility recognized by MCBL for reimbursement purposes.  A Provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.
Provider Network
A set of providers contracted with a health plan to provide services to the enrollees.
|
| A B C D E F G H I J K L M N O P Q R S T U V W X Y Z |
| Same-Day Surgery
Same-day, ambulatory or outpatient surgery is surgery that does not require overnight stay in a hospital.
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.
 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.
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.
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.
Speech Therapy
Treatment of the correction of a speech impairment which resulted from birth, disease, injury, or prior medical treatment
|
| A B C D E F G H I J K L M N O P Q R S T U V W X Y Z |
| 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.
Utilization Management
A review to determine whether covered services that have been provided or are proposed to be provided to you, whether undertaken prior to, concurrent with, or subsequent to the delivery of such services are medically necessary.
Utilization Review
A formal evaluation (prospective, concurrent or retrospective) of the coverage, medical necessity, efficiency or appropriateness of health services and treatment plans. |
| A B C D E F G H I J K L M N O P Q R S T U V W X Y Z |
| Waiting Period
A period of time an individual must wait to become eligible for insurance coverage.
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. |
|
|
|
|
|
Infertility 
Inpatient 
