Medical Insurance Guide
Glossary of Insurance Terminology
Suggestions
for contacting your health plan
Links to Major Health Insurance Companies
The professional fees for your anesthesiologist’s services are separate from your dental bill. Our services are available by request through your pediatric dental office. PDAA (Pediatric Dental Anesthesia Associates) are not providers (out of network) with any insurance company and can not usually accept insurance assignment, BUT your medical insurance may reimburse you directly for part of the anesthesia fee.
You are the customer in this situation and your insurance company will be more responsive to your direct claims. We will gladly help patients who have health insurance receive the maximum benefits provided by your insurance company. Due to its recent introduction within the medical and dental community, many health plans have not formally completed their review of this mode of care or you may find that your specific health plan may not currently consider office-based anesthesia (OBA) for pediatric patients as a covered benefit for treatment of dental conditions. As more parents, such as you, request coverage for OBA for children’s dental treatment, the reimbursement process will get easier and more health plans will cover this.
This guide provides details on how to find out if your
health plan covers office-based anesthesia (OBA) for pediatric patients and for
obtaining pre-authorization approval for
treatment. It overviews the steps you can follow if you have individual health
insurance or group health insurance through your employer.
Step 1. Is your child
a candidate for office-based anesthesia for dental care?
Step 2. Is
office-based anesthesia a covered benefit under your health plan?
Step 3. Requesting
pre-authorization for office-based anesthesia for pediatric patient treatment.
Step 4. Obtaining the
decision
Step
1: Is your child a candidate for
office-based anesthesia (OBA) for dental care?
Contact your pediatrician, dentist, or
the office-based anesthesiologist to begin the prescreening process to
determine if your child is a candidate for OBA for pediatric dental treatment.
Once you have completed the required
evaluation process and it is determined that your child is a candidate for OBA
for pediatric dental treatment, call your insurance company (Step 2) to
determine your child’s eligibility for OBA benefits.
Step
2: Is office-based anesthesia (OBA) a
covered benefit under your health plan?
Contact your health plan by phone or in
writing to ascertain if OBA for pediatric dental treatment is a covered benefit under your plan. Provide them with the
following OBA for pediatric patients Current Procedural Terminology (CPT)
procedure codes:
CPT 00170-00176 – Anesthesia for
Intraoral Procedures
D9220 – Deep sedation/general anesthesia
– first 30 minutes
D9221 – Deep sedation/general anesthesia
– each additional 15 minutes.
Plans determine this by reference to the
codes used to bill for the treatment in question.
If they tell you it is an approved
procedure under your covered benefits, ask them to provide you with the details
and steps if you need to obtain pre-authorization of OBA for pediatric dental
treatment.
If OBA for pediatric patients is not a
covered benefit, ask why it is not currently considered a covered service. They
may answer that it is not considered a “medically
necessary” procedure for the dental treatment, or it is not considered a
covered benefit under your specific plan. Ask them what information and
documentation you need to submit to get them to reconsider their decision to
deny this service. They may ask for a Statement
of Medical Necessity Form which your pediatrician and pediatric dentist can
help you fill out.
Record all contact information (including
the person you are talking with and any person they recommend you contact) and
what is discussed on the phone conversation.
Step 3: Requesting pre-authorization for office-based anesthesia for
pediatric patient treatment.
When reviewing the plan details
of your family health policy, you may find mention of penalties or non-payment
of claims for certain procedures that require pre-authorization. Not obtaining
this pre-authorization for medical services needed for any family member can
dramatically increase your out-of-pocket costs. Your plan details should
clearly outline all procedures that require pre-authorization. However, it is
always a good idea to contact your insurance company in advance of any
scheduled medical procedure to verify that pre-authorization has been given. Ask
for the claims number associated with this pre-authorization and, if possible,
request a faxed copy for your records.
Remember Pre-authorization does not guarantee payment
of benefits.
The pre-authorization request should
include the following detailed information about your medical condition and
your need to undergo OBA for pediatric dental treatment, all of which should be
furnished by your physician (a sample medical necessity form can be found at
pediatricsedation.com Statement
of Medical Necessity Form):
Your pediatrician may ask the health plan
to call him or her with any questions about the letter or the office-based
anesthesia for pediatric dental procedure. You may need letters from your
pediatrician, dentist and/or the anesthesiologist from the OBA practice that
will be performing your OBA for your child’s dental treatment.
Step 4: Obtaining the
decision after Submitting Request for Pre-Authorization
Contact the health plan claims office if
you don’t receive a reply within two weeks and ask when a decision can be
expected. (Many states require insurance companies to respond within 30 days). Record
the date of inquiry and the person with whom you spoke. Be patient and offer to
provide any needed information.
Your health plan must provide a
clinical reason for their decision, whether they approve or deny the request.
Your health plan may deny office-based
anesthesia for pediatric patients, because
Step 5: Appealing a denial
If you are denied, this is their first
response, not necessarily the last. Request a written response, detailing the
reasons for denial. You will then have something specific to answer.
The type of insurance you have determines
whether state or federal law applies to the appeal process. If your plan is
self-funded, then ERISA (federal law) applies and the Department of Labor has
jurisdiction. If it is commercial insurance, state law applies and the state Division
of Insurance (DOI) has jurisdiction.
A. Reconsideration of Denial (grievance letter)
If your health plan denies your request
for treatment, you should request an informal reconsideration (grievance
appeal). You can do this by calling, writing or faxing the health plan.
Contact your health plan to provide you
with the appropriate guidelines for your appeal. It is better to ask for your
reconsideration in the form of a letter, so your request does not get lost. If
you make your request by phone, record the date and who took your request.
Health plans must send you a letter stating that they received your request for
informal reconsideration within 5 days.
In your letter, you should tell the
health plan the reasons why you disagree with their denial. If the reason for
denial is that the service is not considered medically
necessary, ask your pediatrician
to write a letter
of medical necessity. Include in this letter, medical records, and
documentation that supports your position for coverage in your informal
reconsideration letter.
If the service is denied because it
is “investigational”, this objection can be refuted by citing experience with
thousands of office-base anesthetics for pediatric dental patients nationwide.
If your health plan denies
office-based anesthesia for pediatric patients after an informal
reconsideration, you should send a written letter to appeal their decision. You
may ask your physician to write the response.
Check with your health plan for
specific instructions and how long the appeal process takes. It is very
important to submit your appeal as soon as you hear from your health plan that
they have denied your informal reconsideration.
Your appeal letter should directly
address the reason for the denial of office-based anesthesia for pediatric
patients. In the letter, include any additional information not included in
your informal reconsideration letter. If you did not submit a letter of medical
necessity with your informal reconsideration, request your referring physician
write a letter of medical necessity. (See: Letters of Medical
Necessity under Step 3).
Send the appeal to the claims
manager (or the specified contact). Call to make sure it was received.
C. Second
Appeal
If the first appeal is denied, ask
again for the denial in writing. Also, inquire if another appeal is possible,
to a higher-level person or committee. Should you be denied a second time, do
not give up. Answer, or ask your pediatrician to answer, all objections and
resubmit. Be patient and persistent. Many claims have been authorized after two
or more appeals
D. Higher Level
of Appeal - External Independent Review
You must check with your health plan
to see if you have the right to request an external independent review of their
decision to deny coverage of office-based anesthesia for pediatric patients.
Your health plan or employer can explain to you whether your type of insurance
allows for an external review and the steps to take after your appeal is
denied. An external independent review requires that someone, who is not
employed by the health plan, review your request for office-based anesthesia
(OBA) for pediatric patient’s treatment and make a decision independent of the
health plan. You must request this independent review within a certain amount
of time after the health plan denies your appeal for office-based anesthesia
for pediatric patient’s treatment. Your request for this review should be
mailed directly to your health plan.
Your health plan will send your
request for an independent review, along with all of your information, to your
State’s Department of Insurance. There is no charge to you for the external
independent review.
For questions of medical necessity,
the independent physician who reviews your case has 21 days to contact the
Department of Insurance of his or her decision. The Department of Insurance
will send you the decision 5 days following receipt of the decision. For
questions of coverage, the Department of Insurance will mail you a decision
within 15 days of receipt of the independent physician’s review. The external
independent review decision is legally binding on your health plan and you. On
questions of medical necessity, if you disagree with the independent review,
you may have the right to go to court to further your appeal. On questions of
coverage, you or the health plan can ask for fair hearing. Information sent with the independent
review decision will explain the process for requesting a fair hearing.
ADDITIONAL
INFORMATION
Is the appeal
process different if denial was based on decisions of medical necessity versus
questions of coverage?
Yes, the appeals process will differ
depending why your case was denied. The review process used will depend on
whether your case is based on the question of whether office-based anesthesia
for pediatric patients is medically necessary or whether it is a question of coverage.
A question of medical necessity
means that the health plan does not believe that office-based anesthesia for
pediatric dental patients is necessary to treat your child’s dental condition.
In this case, a physician familiar with treating dental disease in pediatric
cases will review all the information you have submitted during the appeals
process and determine if office-based anesthesia for your child is the most
appropriate treatment choice for your specific case.
A question of coverage means the health
plan believes that office-based anesthesia (OBA) for a pediatric patient is not
a covered benefit under the terms of your health insurance policy. An employee
of your State Department of Insurance reviews questions of coverage.
For all independent reviews, it is
very important that they write all the reasons why the denial of office-based
anesthesia for pediatric patients is the wrong decision for your medical
condition. Letters of medical necessity, your medical records, and OBA for
pediatric dental patient support documents from your treating dentist,
pediatrician and the anesthesiologist from the office-based anesthesia practice
are critical for the independent physician to review. Once the external
independent review is in process, contact your State Department of Insurance
directly to make sure they have all your information.
For ERISA
Complaints: If you are
employed by an employer group who is self-insured and does not buy insurance
from an insurance company and is self-funded (meaning that they provide their
own insurance and bear their own risk), your employer must follow a federal
law, the Employee Retirement Income Security Act, known as ERISA. If your
employer has self-insured health insurance, you cannot ask for an external
independent review through the State Department of Insurance. Under ERISA, if
your appeal was denied, you may be entitled to file a complaint with the U. S.
Department of Justice. You can contact them at 1-666-444-3272 or visit their
website at www.dol.gov/ebsa for information on how to file a complaint.
Frequently
Asked Questions
1. What is Office Based Anesthesia
(OBA)?
Anesthesia
provided in an office setting is a safe alternative to hospitals and ambulatory
surgical centers (ASCs). For the pediatric dental patient OBA is more
affordable, convenient and available in the familiar surroundings of your
child’s pediatric dental office.
2.
Will my insurance
company or health plan pay for OBA for my child?
Payment and coverage of office-based anesthesia
for pediatric dental patients will vary from health plan to health plan.
Office-based anesthesia for pediatric dental patients is a recently introduced
for treatment of dental disease. Because this treatment option is relatively
new, few insurance companies reimburse for this as part of their routine
treatment options. It will be necessary for you to contact your health plan to
verify whether it is a covered benefit under your plan policy. At this time,
payment for office-based anesthesia for pediatric patients may be based on
individual payer discretion and coverage may be determined on a case-by-case
basis.
3. Do I need to get pre-authorization
before treatment?
Yes, you will have to contact your health
plan for pre-authorization of office-based anesthesia for pediatric dental
treatment prior to scheduling your child’s dental treatment session. We suggest
you work with your referring pediatrician and/or staff at the dentist’s office
you have been referred to for treatment. Prior to contacting your health plan,
we recommend your referring pediatrician document the reason office-based
anesthesia for pediatric dental treatment is the most appropriate treatment for
your specific case. Either your referring pediatrician, or a dentist, will need
to provide you with documentation that supports medical necessity for treatment
of your child’s dental condition and their choice of office-based anesthesia
for pediatric patients as the best treatment option.
4. What if I need
office-based anesthesia for my child immediately and my health plan denies my
request?
If your health plan denies
office-based anesthesia for pediatric patients and it is determined you need
these treatment immediately, you can request an Expedited Medical Review.
The purpose of an Expedited Medical Review is to require that the health plan to
make a quick decision because your child’s health is at risk. Your referring
pediatrician must certify in writing that delaying this service could cause a
significant negative change in your medical condition. The health plan cannot
question your physician’s certification and it must make a decision 1 business
day after receiving the certification and other supporting information. If the
health plan still denies OBA for your child, you can appeal and ask for an
external independent review. The time allowed for the health plan to respond to
this type of request is very short. Contact your State Department of Insurance
and request information on Expedited Medical Review.
5. What should I do if my health plan
denies my request for office-based anesthesia for pediatric dental treatment in
the pre-authorization process?
For office-based anesthesia for pediatric
patients to be approved by your health plan through the pre-authorization
process, 3 conditions must be met:
(a) They must agree that treatment is necessary for your
condition,
(b) They must agree office-based anesthesia for pediatric
patients is an appropriate treatment for your condition,
(c) They must agree to reimburse for this treatment.
If you complete the pre-authorization
process and your plan does not consider OBA for pediatric patients a covered
benefit (or medically necessary) and denies your initial request for treatment,
you are entitled to initiate a general grievance review of their denial
decision. You must contact your health plan to outline the protocol for the
grievance process. You will need to follow the guidelines established by your
health plan. You may also be entitled to a second more formal independent
review process if your health plan denies treatment under the grievance
process. You must exhaust the grievance process before attempting to initiate
the independent review process.
6. What are the reasons why a health
plan will refuse to cover OBA for my child’s dental treatment?
A health plan will base their denial on a
combination of three different rulings. The plan may rule that office-based
anesthesia for pediatric patients is a “non-covered service” for its eligible
members; it is “not medically-necessary” for the treatment of dental disease or
for a patient specific case; or from an insurance company perspective, they
consider this an “experimental or investigational” treatment. Your right to an
external independent review will be dependent on the reason cited for the
denial and your health plan’s eligibility criteria for an independent review of
a denial made through the grievance process.
7. Do I need to write a letter of
appeal and forward it to my health plan?
For both the grievance and the
independent review process, you are typically required to formally appeal their
denial decision in writing. Prior to writing your appeals letter, go to the Web
page for your health plan, or contact them directly for specific instructions
on what written documentation is required to support your request for a review
if their decision to deny approval. Work with your referring pediatrician and
dentist and their staff to provide the appropriate documents you will need to
start the appeals process. In addition to a letter of appeal, health plans
require additional support documents including a letter from your referring
physician (pediatrician) recommending office-based anesthesia for your child
and the reasons why office-based anesthetic for your child should be a covered
benefit for your specific case. Additionally, other support documents that are
needed include peer reviewed literature that demonstrates clinical efficacy and
cost-effectiveness, medical literature and second opinions supporting medical
necessity, copies of all information provided to the health plan during the
appeals process, and all documentation received from the health plan during the
appeals process documenting the reason for the denial.
8. What happens if I exhaust all
levels of appeal?
Once you feel you have exhausted all
avenues of appeal, you may want to consider other options for office-based
anesthesia for your child’s dental treatment. Under some health plans, there
are legal remedies available under state, federal, Medicare, or ERISA
regulations. For those who seek treatment outside of continued appeals or legal
remedy, patient self-pay options may be a viable consideration. The majority of
OBA practices providers offer Self-Pay programs for patients desiring
treatment. Please contact either your referring physician or your OBA
anesthesiologist to discuss financing options and alternative payment programs.
9. Do I have any other choices?
Yes. Because for some patients the need
for treatment is urgent, or the patient feels this is the treatment method of
choice, many decide to move forward with the treatment and pay for the
procedure out of pocket. You must first contact your health plan and get a
formal denial of pre-authorization of OBA for your child’s dental treatment.
Once you have this denial, you do have the right to appeal their non-coverage
decision and denial of payment and request, either through your employer or
health plan to be reimbursed for the expense.
Suggestions for contacting your health plan:
Know the
Details of Your Health Insurance Policy
When you are shopping for
family health insurance, the plan details that are available to you are just an
overview of the details of the policy. You are provided with a summary of
benefits, but not all of the details of the policy. This may be available to
you upon request, but is typically not provided until you have been approved
for coverage and become a plan member. For group health insurance, the
insurance company will send you the health plan details once you have enrolled
in the group health plan. The plan details, also referred to as "evidence
of coverage," is a booklet that provides you with all of the details about
the plan in which you are enrolled. This will include a list of all the medical
benefits that are covered under your family health plan, but in much greater
detail than a standard benefit summary
Glossary
of Insurance Terminology
A
Actuary:
A mathematician working for a health insurance company responsible for
determining what premiums the company needs to charge based in large part on
claims paid verses amounts of premium generated. Their job is to make sure a
block of business is priced to be profitable.
Admitting Privileges: The right granted to a doctor to admit patients to a particular hospital.
Advocacy:
Any activity done to help a person or group to get something the person or
group needs or wants.
Agent:
Licensed salespersons who represent one or more health insurance companies and
presents their products to consumers.
Association: A group. Often, associations can offer individual health insurance plans
specially designed for their members.
B
Benefit: Amount payable by the
insurance company to a claimant, assignee, or beneficiary when the insured
suffers a loss.
Brand-name drug: Prescription drugs marketed with a specific brand name by the company that
manufactures it, usually the company which develops and patents it. When
patents run out, generic versions of many popular drugs are marketed at lower
cost by other companies. Check your insurance plan to see if coverage differs
between name-brand and their generic twins.
Broker:
Licensed insurance salesperson who obtains quotes and plan from multiple
sources information for clients.
C
Capitation:
Capitation represents a set dollar limit that you or your employer pay to a
health maintenance organization (HMO), regardless of how much you use (or don't
use) the services offered by the health maintenance providers. (Providers is a
term used for health professionals who provide care. Usually providers refer to
doctors or hospitals. Sometimes the term also refers to nurse practitioners,
chiropractors and other health professionals who offer specialized services.)
Carrier:
The insurance company or HMO offering a health plan.
Case Management: Case management is a system embraced by employers and insurance companies
to ensure that individuals receive appropriate, reasonable health care
services.
Certificate of Insurance: The printed description of the benefits and coverage provisions forming
the contract between the carrier and the customer. Discloses what it covered,
what is not, and dollar limits.
Claim:
A request by an individual (or his or her provider) to an individual's
insurance company for the insurance company to pay for services obtained from a
health care professional.
Co-Insurance: Co-insurance refers to money that an individual is required to pay for
services, after a deductible has been paid. In some health care plans,
co-insurance is called "co-payment." Co-insurance is often specified
by a percentage. For example, the employee pays 20 percent toward the charges
for a service and the employer or insurance company pays 80 percent.
Co-Payment:
Co-payment is a predetermined (flat) fee that an individual pays for health
care services, in addition to what the insurance covers. For example, some HMOs
require a $10 "co-payment" for each office visit, regardless of the
type or level of services provided during the visit. Co-payments are not
usually specified by percentages.
COBRA:
Federal legislation that lets you, if you work for an insured employer group of
20 or more employees, continue to purchase health insurance for up to 18 months
if you lose your job or your coverage is otherwise terminated. For more
information, visit the Department of Labor.
Credit for Prior Coverage: This is something that may or may not apply when you switch employers or
insurance plans. A pre-existing condition waiting period met under while you
were under an employer's (qualifying) coverage can be honored by your new plan,
if any interruption in the coverage between the two plans meets state
guidelines.
D
Deductible:
The amount an individual must pay for health care expenses before insurance (or
a self-insured company) covers the costs. Often, insurance plans are based on
yearly deductible amounts.
Denial Of Claim: Refusal by an insurance company to honor a request by an individual (or
his or her provider) to pay for health care services obtained from a health
care professional.
Dependent Worker: A worker in a family in which someone else has greater personal income.
Dependents:
Spouse and/or unmarried children (whether natural, adopted or step) of an insured.
E
Effective Date: The date your insurance is to actually begin. You are not covered until
the policies effective date.
Employee Assistance Programs (EAPs): Mental health counseling services that are sometimes offered by insurance
companies or employers. Typically, individuals or employers do not have to
directly pay for services provided through an employee assistance program.
Exclusions:
Medical services that are not covered by an individual's insurance policy.
Explanation of Benefits: The insurance company's written explanation to a claim, showing what they
paid and what the client must pay. Sometimes accompanied by a benefits check.
G
Generic Drug: A "twin" to a "brand name drug" once the brand name
company's patent has run out and other drug companies are allowed to sell a
duplicate of the original. Generic drugs are cheaper, and most prescription and
health plans reward clients for choosing generics.
Group Insurance: Coverage through an employer or other entity that covers all individuals in
the group.
H
Health Care Decision Counseling: Services, sometimes provided by insurance companies or employers, which
help individuals weigh the benefits, risks and costs of medical tests and
treatments. Unlike case management, health care decision counseling is
non-judgmental. The goal of health care decision counseling is to help
individuals make more informed choices about their health and medical care
needs, and to help them make decisions that are right for the individual's
unique set of circumstances.
Health Maintenance Organizations
(HMOs): Health Maintenance Organizations represent
"pre-paid" or "capitated" insurance plans in which
individuals or their employers pay a fixed monthly fee for services, instead of
a separate charge for each visit or service. The monthly fees remain the same,
regardless of types or levels of services provided, Services are provided by
physicians who are employed by, or under contract with, the HMO. HMOs vary in
design. Depending on the type of the HMO, services may be provided in a central
facility, or in a physician's own office (as with IPAs.)
HIPAA:
A Federal law passed in 1996 that allows persons to qualify immediately for
comparable health insurance coverage when they change their employment or
relationships. It also creates the authority to mandate the use of standards
for the electronic exchange of health care data; to specify what medical and
administrative code sets should be used within those standards; to require the
use of national identification systems for health care patients, providers,
payers (or plans), and employers (or sponsors); and to specify the types of
measures required to protect the security and privacy of personally
identifiable health care. Full name is "The Health Insurance Portability
and Accountability Act of 1996."
I
In-network:
Providers or health care facilities which are part of a health plan's network
of providers with which it has negotiated a discount. Insured individuals
usually pay less when using an in-network provider, because those networks
provide services at lower cost to the insurance companies with which they have
contracts.
Indemnity Health Plan: Indemnity health insurance plans are also called
"fee-for-service." These are the types of plans that primarily
existed before the rise of HMOs, IPAs, and PPOs. With indemnity plans, the
individual pays a pre-determined percentage of the cost of health care
services, and the insurance company (or self-insured employer) pays the other
percentage. For example, an individual might pay 20 percent for services and
the insurance company pays 80 percent. The fees for services are defined by the
providers and vary from physician to physician. Indemnity health plans offer
individuals the freedom to choose their health care professionals.
Independent Practice Associations: IPAs are similar to HMOs, except that individuals receive care in a
physician's own office, rather than in an HMO facility.
Individual Health Insurance: Health insurance coverage on an individual, not group, basis. The premium
is usually higher for an individual health insurance plan than for a group
policy, but you may not qualify for a group plan.
L
Lifetime Maximum Benefit (or Maximum
Lifetime Benefit): the maximum amount a health plan
will pay in benefits to an insured individual during that individual's
lifetime.
Limitations: a limit on the amount of benefits paid out for a particular covered
expense, as disclosed on the Certificate of Insurance.
Long-Term Care Policy: Insurance policies that cover specified services for a specified period of
time. Long-term care policies (and their prices) vary significantly. Covered
services often include nursing care, home health care services, and custodial
care.
Long-term Disability Insurance: Pays an insured a percentage of their monthly earnings if they become
disabled.
LOS:
LOS refers to the length of stay. It is a term used by insurance companies,
case managers and/or employers to describe the amount of time an individual
stays in a hospital or in-patient facility.
M
Managed care adjective Referring to a
covered service or treatment that is absolutely necessary to protect and
enhance the health status of a Pt, and could adversely affect the Pt's
condition if omitted, in accordance with accepted standards of medical
practice.
Managed Care: A medical delivery system that attempts to manage the quality and cost of
medical services that individuals receive. Most managed care systems offer HMOs
and PPOs that individuals are encouraged to use for their health care services.
Some managed care plans attempt to improve health quality, by emphasizing
prevention of disease.
Maximum Dollar Limit: The maximum amount of money that an insurance company (or self-insured
company) will pay for claims within a specific time period. Maximum dollar
limits vary greatly. They may be based on or specified in terms of types of
illnesses or types of services. Sometimes they are specified in terms of
lifetime, sometimes for a year.
Medigap Insurance Policies: Medigap insurance is offered by private insurance companies, not the
government. It is not the same as Medicare or Medicaid. These policies are
designed to pay for some of the costs that Medicare does not cover.
Multiple Employer Trust (MET): A trust consisting of multiple small employers in the same industry,
formed for the purpose of purchasing group health insurance or establishing a
self-funded plan at a lower cost than would be available to each of the
employers individually.
N
Network:
A group of doctors, hospitals and other health care providers contracted to
provide services to insurance company’s customers for less than their usual
fees. Provider networks can cover a large geographic market or a wide range of
health care services. Insured individuals typically pay less for using a
network provider.
O
Open-ended HMOs: HMOs which allow enrolled individuals to use out-of-plan providers and
still receive partial or full coverage and payment for the professional's
services under a traditional indemnity plan.
Out-of-Plan
(Out-of-Network): This phrase usually refers to physicians, hospitals or
other health care providers who are considered nonparticipants in an insurance
plan (usually an HMO or PPO). Depending on an individual's health insurance
plan, expenses incurred by services provided by out-of-plan health
professionals may not be covered, or covered only in part by an individual's
insurance company.
Out-Of-Pocket Maximum: A predetermined limited amount of money that an individual must pay out of
their own savings, before an insurance company or (self-insured employer) will
pay 100 percent for an individual's health care expenses.
Outpatient:
An individual (patient) who receives health care services (such as surgery) on
an outpatient basis, meaning they do not stay overnight in a hospital or
inpatient facility. Many insurance companies have identified a list of tests
and procedures (including surgery) that will not be covered (paid for) unless
they are performed on an outpatient basis. The term outpatient is also used
synonymously with ambulatory to describe health care facilities where
procedures are performed.
P
Plan Administration: Supervising the details and routine activities of installing and running a
health plan, such as answering questions, enrolling individuals, billing and
collecting premiums, and similar duties.
Pre-Admission Certification: Also called pre-certification review, or pre-admission review. Approval by
a case manager or insurance company representative (usually a nurse) for a
person to be admitted to a hospital or in-patient facility, granted prior to
the admittance. Pre-admission certification often must be obtained by the
individual. Sometimes, however, physicians will contact the appropriate
individual. The goal of pre-admission certification is to ensure that
individuals are not exposed to inappropriate health care services (services
that are medically unnecessary).
Pre-Admission Review: A review of an individual's health care status or condition, prior to an
individual being admitted to an inpatient health care facility, such as a
hospital. Pre-admission reviews are often conducted by case managers or
insurance company representatives (usually nurses) in cooperation with the
individual, his or her physician or health care provider, and hospitals.
1. The approval of or
concurrence with the treatment plan proposed by a participating dental
professional before the provision of service. Under some plans,
preauthorization by the carrier is required before certain services can be
provided.
2. A statement by a third-party payer indicating that proposed treatment
will be covered under the terms of the dental benefits contract.
Pre-existing Conditions: A medical condition that is excluded from coverage by an insurance
company, because the condition was believed to exist prior to the individual
obtaining a policy from the particular insurance company.
Preadmission Testing: Medical tests that are completed for an individual prior to being admitted
to a hospital or inpatient health care facility.
Preferred Provider Organizations
(PPOs): You or your employer receives discounted rates if you
use doctors from a pre-selected group. If you use a physician outside the PPO
plan, you must pay more for the medical care.
Primary Care Provider (PCP): A health care professional (usually a physician) who is responsible for
monitoring an individual's overall health care needs. Typically, a PCP serves
as a "quarterback" for an individual's medical care, referring the
individual to more specialized physicians for specialist care.
Provider:
Provider is a term used for health professionals who provide health care
services. Sometimes, the term refers only to physicians. Often, however, the
term also refers to other health care professionals such as hospitals, nurse
practitioners, chiropractors, physical therapists, and others offering
specialized health care services.
R
Reasonable and Customary Fees: The average fee charged by a particular type of health care practitioner
within a geographic area. The term is often used by medical plans as the amount
of money they will approve for a specific test or procedure. If the fees are
higher than the approved amount, the individual receiving the service is
responsible for paying the difference. Sometimes, however, if an individual
questions his or her physician about the fee, the provider will reduce the
charge to the amount that the insurance company has defined as reasonable and
customary.
Rider:
A modification made to a Certificate of Insurance regarding the clauses and
provisions of a policy (usually adding or excluding coverage).
Risk:
The chance of loss, the degree of probability of loss or the amount of possible
loss to the insuring company. For an individual, risk represents such
probabilities as the likelihood of surgical complications, medications' side
effects, exposure to infection, or the chance of suffering a medical problem
because of a lifestyle or other choice. For example, an individual increases
his or her risk of getting cancer if he or she chooses to smoke cigarettes.
S
Second Opinion: It is a medical opinion provided by a second physician or medical expert,
when one physician provides a diagnosis or recommends surgery to an individual.
Individuals are encouraged to obtain second opinions whenever a physician
recommends surgery or presents an individual with a serious medical diagnosis.
Second Surgical Opinion: These are now standard benefits in many health insurance plans. It is an
opinion provided by a second physician, when one physician recommends surgery
to an individual.
Short-Term Disability: An injury or illness that keeps a person from working for a short time.
The definition of short-term disability (and the time period over which
coverage extends) differs among insurance companies and employers. Short-term
disability insurance coverage is designed to protect an individual's full or
partial wages during a time of injury or illness (that is not work-related)
that would prohibit the individual from working.
Short-Term Medical: Temporary coverage for an individual for a short period of time, usually
from 30 days to six months.
Small Employer Group: Generally means groups with 1 99 employees. The definition may vary
between states.
State Mandated Benefits: When a state passes laws requiring that health insurance plans include
specific benefits.
Stop-loss:
The dollar amount of claims filed for eligible expenses at which point you've
paid 100 percent of your out-of-pocket and the insurance begins to pay at 100%.
Stop-loss is reached when an insured individual has paid the deductible and
reached the out-of-pocket maximum amount of co-insurance.
T
Triple-Option: Insurance plans that offer three options from which an individual may
choose. Usually, the three options are traditional indemnity, an HMO, and a
PPO.
U
Underwriter: The Company that assumes responsibility for the risk issues insurance
policies and receives premiums.
Usual, Customary and Reasonable
(UCR) or Covered Expenses: An amount customarily
charged for or covered for similar services and supplies which are medically
necessary, recommended by a doctor, or required for treatment.
W
Waiting Period: A period of time when you are not covered by insurance for a particular
problem.
LINKS TO MAJOR HEALTH INSURANCE COMPANIES
Blue Cross Blue Shield of Florida http://www.bcbsfl.com/
Aetna https://www.aetna.com/member/
Cigna http://www.cigna.com/
AV Med http://www.avmed.org/
United Healthcare http://www.uhc.com/