Insurance Policy Definitions

Insurance Policy Definitions

Accident – An unintended occurrence outside the normal course of events that causes illness, injury or damage to a person or property.

Authorization (Precertification): An approval process for requested medical services, either by the health care provider or the patient, to determine if a request is covered for reimbursement. Authorization or precertification is determined by eligibility, plan benefits and medical necessity of the service being requested.

Benefits: Determination of which services rendered will be reimbursed by an insurance plan. Services will be reimbursed at a portion of the cost as determined by the contracted rates. These services include hospitalization, diagnostic tests, services rendered by health care providers, durable medical equipment and prescriptions.

Bundled Service: An individual service that is included in a more complex or comprehensive service and billed on the same date of service as the more comprehensive service.

Code Editing Logic: A review and evaluation tool for accuracy and adherence of medical claims to accepted national industry standards, plan benefits and authorization guidelines.

Code Set: “[A]ny set of codes used for encoding data elements, such as tables of terms, medical concepts, medical diagnostic codes or medical procedure codes.”

Conditional Payment – A Medicare payment, conditioned upon reimbursement to Medicare, for services for which another insurer is primary payer.

Consistency Guidelines: System logic that identifies services that are inconsistent in nature, including: gender-specific services provided to a member of the opposite sex; age-specific services provided to a member not in the appropriate age range; surgical procedure performed on a member who previously has had the respective organ or only body part of that kind removed.

Covered Services: Health care services the contractor provides to enrollees, including all services required by contract, state and federal law, and all additional services described by the contractor.

Employee – An individual who is working for an employer or an individual who, although not actually working for an employer, is receiving from an employer payments that are subject to FICA taxes or would be subject to FICA taxes except that the employer is exempt from those taxes under the Internal Revenue Code (IRC).

Family Member – Family member means a person enrolled in a GHP based on another person’s enrollment. Family members may include, but are not limited to, a spouse (including a divorced or common-law spouse); a natural, adopted or foster child; a stepchild; a parent; or a sibling.

Fee Schedule: A list of pre-established allowances for specific services.

Global Allowance: Denotes that reimbursement for surgical procedures includes the preoperative services, surgical operation and uncomplicated postoperative-care visits.

Incidental Procedure: One or more of the procedures performed during multiple surgery situations considered an integral part of the major (more complex) or primary procedure; also referred to as integral.

Level of Care: The intensity of professional medical care required to achieve the treatment objectives for a specific episode of care.

Medical Necessity Criteria: Clinical determinations to establish a service or benefit that will or is reasonably expected to:

* Assist the individual to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual and those functional capacities appropriate for individuals of the same age

* Prevent the onset of an illness, condition or disability

* Reduce or ameliorate the physical, mental, behavioral or developmental effects of an illness, condition, injury or disability.

Medical Records: Reports, notes, photographs, X-rays or other recorded data or information (whether maintained in written, electronic or another form) that is received or produced by a health care provider or any person employed by the provider. These items contain information relating to the medical history, examination, diagnosis or treatment of the member for an identified episode of care for specific dates of service.

Modifier: “A modifier is a two-digit numeric or alphanumeric character reported with a Healthcare Procedure Coding System (HCPCS) code when appropriate. Modifiers are designed to give Medicare and commercial payers additional information needed to process a claim. This includes HCPCS Level I (Physicians’ Current Procedural Terminology [CPT]) and HCPCS Level II codes. A modifier provides the means by which a physician or facility can indicate or ‘flag’ a service provided to the patient that has been altered or affected by some special circumstances, but for which the basic code description itself has not changed.” [Ingenix Learning: Understanding Modifiers, 2008 ed]

Mutually Exclusive Procedures: Two or more procedures that differ in technique or approach but lead to the same outcome; also, an initial service and subsequent service are considered mutually exclusive.

Ordering physician – is a physician or, when appropriate, a non-physician practitioner who orders non-physician services for the patient.Examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, and services incident to that physician’s or non-physician practitioner’s service.

Proper Claim – A claim that is filed timely and meets all other claims filing requirements specified by the plan, program or insurer (e.g., mandatory second opinion, prior notification before seeking treatment).

Recoup Payments: Retraction of monies paid to providers from future payments.

Recover Payments: Request for provider to return payment to Amerigroup.

Referring physician – is a physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.

Routine Medical and Surgical Supplies: Supplies used during an outpatient or physician’s office visit; considered included.

Subrogation – Subrogation means the substitution of one person or entity for another. Under the Medicare subrogation provision, the program is a claimant against the responsible party and the liability insurer to the extent that Medicare has made payments to or on behalf of the beneficiary.

Unbundled Services: Individual procedure codes are billed when it is more appropriate to bill a single comprehensive code that indicates the specific group of procedures was performed (bundled service).

Under-Insured Motorist Insurance – Insurance under which the policyholder’s level of protection against losses caused by another is extended to compensate for inadequate coverage in the party’s policy or plan.

Uninsured Motorist Insurance – Insurance under which the policyholder’s insurer pays for damages caused by a motorist who has no automobile liability insurance or carries less than the amount of insurance required by law.

Self-Insured Plan – A plan under which an individual or other entity is authorized by state law to carry its own risk instead of taking out insurance with a carrier. “Authorized by state law” means not prohibited by state law. The plan established for the federal government under the Federal Tort Claims Act is also a self-insured plan.

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