Glossary

See 'Intensive Care Unit'.

A card which allows the subscriber to identify himself or his covered dependents to a provider for health care services.  

A unique number which identifies the member's enrollment with EmblemHealth. EmblemHealth's claims are processed by this number.

A claim that has been received by EmblemHealth, but has not been finalized.

A member that does not have coverage with EmblemHealth.

A tradition health insurance plan that reimburses for services provided to patients based on bills submitted after the services are rendered. Also known as fee-for-service plans. These plans generally do not have a specific provider network.

A type of health insurance product characterized by reimbursement on a fee for service basis, freedom of choice in selecting providers and fewer managed care rules and regulations.

An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide healthcare services.

The dollar amount of the member's health benefit coverage that must be met based on allowable charges each calendar year before becoming eligible for benefits for the remaining cost of covered services. Once the deductible is reached, all claims are then paid at 100% of allowable charges.

Term used to describe the inability to conceive or an inability to carry a pregnancy to a live birth after a year or more of regular sexual relations without the use of contraception.

Treatment accomplished by placing therapeutic agents into the vein, including intravenous feeding. Such therapy also includes enteral nutrition that is the delivery of nutrients into the gastrointestinal tract by tube.

Clinical review conducted by appropriate licensed or certified health professionals. Initial clinical review staff may approve requests for admissions, procedures, and services that meet clinical review criteria.

Refers to the use of providers who participate in the health plan's provider network. Many benefit plans encourage enrollees to use participating (in-network) providers to reduce the enrollee's out-of-pocket expense.

A healthcare provider such as a physician, skilled nursing facility, home health agency, laboratory etc, who has an agreement with EmblemHealth to provide covered services to members.

Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.

Treatment that is provided to a patient who stays overnight (more than 23 hours) in a hospital or other facility.

A specialized unit in the hospital which concentrates on seriously ill patients needing constant nursing care and observation.

See 'Independent Practice Association'.

A bill from a provider that itemizes all charges for services rendered needed to process for payment.