Benefit
Dollar amount payable for a covered service after application of deductibles
and co-insurance under the health plan which covers the enrollee, subject
to all terms and provisions of such plan.
Benefit Plan
The individual or group health care contract of a payor, including insurance
policies, self-insured plan, third party administrator agreements, governmental
programs, etc.
Covered Services
The health care services and supplies that may be reimbursed pursuant
to a Benefit Plan.
Eligible Person or Enrollee
The person entitled to receive covered services pursuant to a benefit
plan offered by a CSHP payor.
Managed Care
A healthcare delivery system that measures performance and focuses on
costs and utilization of services. Quality and cost-effective care are
the system's goal.
Non-participating
A provider who has not contracted with a health plan to be a participating
health care provider.
Participating Provider
A hospital, physician, or an ancillary facility that has contracted with
a health plan to provide medical services to a covered person. The contracted
participating provider has agreed to accept the terms and conditions established
by the health plan.
Payor
The insurance company, third party administrator, self-insured employer
or other entity that pays health insurance claims on behalf of eligible
persons.
Preferred Provider Organization (PPO)
A program in which healthcare providers contract with a specific health
plan to provide medical services to the covered persons in the plan. The
providers under contract are known as Preferred Providers, and include
hospitals, physicians and other medical facilities. The covered person
is encouraged to use the preferred providers in order to gain the maximum
benefit from their plan. The enrollee may also use a non-participating
provider at reduced benefit levels.
Tertiary
A health care facility or provider that offers highly specialized services
that are not offered with the local network. Generally a visit to a Tertiary
Care Provider requires notification and/or approval from your insurance or
medical management company.
Utilization Management (UM)
UM is the evaluation of necessity, appropriateness and efficiency of healthcare
services. Information is gathered on the proposed hospitalization or services
from the provider and/or patient to determine whether the services meet
the established guidelines and criteria.
