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An insurance company that either administers insurance or self-insures.
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.
This number is noted on the ID card and is the code used to identify the subscriber's type of coverage. Your category number will consist of an arrangement of 3 digits (numbers or letters).
The Governmental agency responsible for administering the Medicare and Medicaid programs.
See ID Number.
Your Certificate of Insurance is evidence of your coverage under the Group Contract between EmblemHealth and your group. Your Certificate of Insurance will typically consist of a booklet along with an Attachment (the "Certificate Attachment") and any applicable riders or amendments. Together these documents describe the health insurance benefits that are available to you from EmblemHealth as well as other important applicable information to your coverage.
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.
Treatment of malignant disease by chemical or biological antinoeplastic agents.
The Children’s Health Insurance Program (CHIP) offers coverage to low- and moderate-income children. Like Medicaid, it is paid for and managed by the states and the federal government.
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.
A pattern of medical care that focuses on long-term care with chronic diseases or conditions.
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.
An application for payment of benefits under a healthcare plan.
A clinical decision is a decision about your medical treatment.
Doctors, nurses and other healthcare professionals are clinical professionals.
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.
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.
A clinical review is when a clinical professional reviews information about your health.
See 'Coordination Of Benefits'.
See 'Consolidated Omnibus Budget Reconciliation Act'.
Coinsurance is a percentage of the Allowed Charge that is payable by you, not EmblemHealth, for covered services rendered by a non-participating provider. After you have met your deductible, EmblemHealth will pay a percentage of the Allowed Charge for those covered services. You are responsible to pay the remaining percentage of the Allowed Charge. This remaining percentage is your "coinsurance" charge. The coinsurance for a covered service will typically be identified in your Certificate or the Attachment to your Certificate. Expenses credited toward your deductible, charges for services that are not covered, and charges in excess of EmblemHealth's allowances and benefit limitations are also payable by you, but are not considered to be coinsurance.
The most you will have to pay in out-of-pocket costs for coinsurance on covered services during a calendar year.
A verbal or written inquiry from a member or provider expressing dissatisfaction with any aspect of their care, coverage or specifically with EmblemHealth.
EmblemHealth covers a comprehensive re-evaluation visit at the initial visit reimbursement level for established patients when 365 days have elapsed since the last encounter with the physician, and a complete history and physical examination are performed.
A federal act which requires eligible 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.
Services rendered by a physician whose opinion or advice is requested by another physician for further evaluation or management of the patient.
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. For example, if an individual is a member of a health plan that relies on the services of a utilization management organization, then the individual is a consumer of the utilization management organization.
Consumer-directed health plans (CDHPs) generally refer to plans that are designed to make consumers more active and aware purchasers of health care by giving them a greater stake in their care (and in their spending for health care). Because CDHPs are often High Deductible Health Plans, their premiums are lower than those for normal managed plans. If used with a health savings accounts (HSA) or a health reimbursement account (HRA), a CDHP can be used to pay for routine health costs with tax-deferred funds. Unused funds can be rolled over to the next plan year.
Procedure by which individuals transferring from one insurance plan to another are allowed uninterrupted coverage from the date of original enrollment.
The process by which pregnancy is prevented by either barring conception of an embryo or the implantation of it within the uterine wall.
A legal agreement between an individual subscriber or an employer group and a health plan that describes the benefits and limitations of the coverage.
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.
A business entity that performs delegated functions on behalf of the insurer or managed care organiation.
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 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."
When a subscriber is covered by more than one benefits plan, with both providing similar benefits, EmblemHealth coordinates with the other carrier to ensure appropriate reimbursement.
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.
A comprehensive term for the deductible, copayment, and coinsurance provisions in your plan.
The services for which EmblemHealth provides benefits under the terms of your contract.
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.
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).
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.
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