Elkhart Medical Organization Managed Care Terms
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  600 East Boulevard
  Elkhart, Indiana 46514
  574-523-3436 (phone)
  800-543-3195
  574-523-7940 (fax)
Choose a term to view its definition...
Acute Care Ancillary Care
Birth Defect Case Management
Coinsurance Coordination of Benefits (COB)
Copay or Copayment Covered Life
Credentialing Deductible
Durable Medical Equipment Employee Retirement Income
Security Act (ERISA)
Experimental Procedures Explanation of Benefits/EOB
Facility Formulary
Gatekeeper Health Insurance Portability
and Accountability Act (HIPAA)
of 1996 or Kennedy Kassebaum Act
Health Maintenance Organization
(HMO)
Home Health Care
Home Infusion Therapy Hospice
In-Network Integrated Delivery Systems
(IDS)
Managed Care Medical Service Organization (MSO)
Member National Committee on Quality
Assurance (NCQA)
Occupational Therapy Orthotics
Out-of-Network Palliative Care
Participating Provider Payor (usually Third Party Payor)
Physical Therapy Physician Hospital Organization (PHO)
Point of Service (POS) Precertification
Preferred Provider Organization
(PPO)
Primary Care Physician (PCP)
Prosthetsis Provider
Reinsurance Service Area
Specialist/Specialty Care Physician Speech Therapy
Third Party Administrator (TPA) Utilization Review





















































































































































































Acute Care -

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Ancillary Care - Diagnostic and/or supportive services such as radiology, physical therapy, pharmacy or laboratory work.

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Birth Defect - A problem that develops with the fetus in the mother's body usually in the first three months of pregnancy. Birth defects can vary from mild to severe, some of which may require surgery.

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Case Management - A system for assessing, planning, treating, referring, and following up on patients to ensure continuity of care through the provision of coordinated and comprehensive services. The system is designed to ensure that care is provided in the most cost-effective settings.

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Coinsurance - Portion of covered health care costs for which the covered person has a financial responsibility, usually a fixed percentage.

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Coordination of Benefits (COB) - Provisions for insurance payment when a member is covered by more than one health insurance contract. This prevents over payment or duplication of benefits by billing the pre-determined primary insurance first, then billing the secondary insurance, taking into account the primary payment.

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Copay or Copayment - Cost-sharing arrangement in which the member pays a specified share of the charge for the medical service, such as $10 for an office visit.

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Covered Life - The term used by third party payors to refer to each individual covered in an insurance plan; includes subscribers and dependents. Frequently, Covered Lives are referred to as Members.

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Credentialing - Obtaining and reviewing the documentation of providers and facilities, such as licensure, certifications, insurance, evidence of malpractice insurance, and malpractice history. Generally includes reviewing information provided by the provider and verifying that the information is correct and complete. Also refers to obtaining hospital privileges and other privileges to practice medicine.

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Deductible - Amount of eligible expense a covered person must pay each year from his/her own pocket before a plan will make payment for eligible benefits.

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Durable Medical Equipment - Equipment that can withstand repeated use and is primarily and usually to serve a medical purpose, is generally not useful in the absence of illness or injury, and is appropriate for use in the home.

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Employee Retirement Income Security Act (ERISA) - One provision of this Act allows self-funded employer plans to avoid paying premium taxes, complying with state-mandated benefits, or otherwise complying with state laws and regulations on insurance. Another provision requires plans and insurance companies to provide an explanation of benefits (EOB) statement to a member of covered insured in the event of a denial of a claim, explaining why the claim was denied and informing the individuals of his or her rights of appeal.

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Experimental Procedures - Experimental, investigational or unproven procedures and treatments.

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Explanation of Benefits/EOB - A statement provided by the payor or insurance company that explains the medical services provided, the allowable reimbursement amounts, any deductibles, coinsurance or other adjustments taken and the net amount paid. A member typically receives an explanation of benefits with a claim reimbursement check or as a confirmation that a claim has been paid directly to a provider. The provider typically receives an explanation of payment.

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Facility - Hospital, group practice, nursing home or pharmacy who provide health care services to Members.

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Formulary - A list of preferred, commonly prescribed prescription drugs. These drugs are chosen by a team of doctors and pharmacists because of their clinical superiority, safety, ease of use and cost.

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Gatekeeper - Refers to the Primary Care Physician (PCP) responsible for determining the quantity and mix of services a patient needs. The gatekeeper also controls the patient's access to and use of services through the continuum of medical care services.

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Health Insurance Portability and Accountability Act (HIPAA) of 1996 or Kennedy Kassebaum Act - Legislation intended to provide portability of employer-sponsored insurance from one job to another in order to prevent what has become known as "job lock" or the inability to change jobs because of the fear of losing health insurance. This act makes it illegal to exclude people from coverage because of pre-existing conditions and offers some tax deductions to self employed people who pay their own health insurance premiums. This act has been updated recently to include provisions for health care providers, health plans and clearinghouses. Directly impacted are Privacy or Protected Health Information (PHI) about patients; Electronic Data Interfaces (EDI) concerning patient health, administrative, and financial data; and Security methods for communication of any of the above. The goal is to improve efficiency in healthcare delivery through standardization as well as protection of confidentiality and security of health data.

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Health Maintenance Organization (HMO) - A legal corporation that offers health insurance and medical care. HMOs provide a range of comprehensive health care services for a specified group at a fixed periodic rate. They can be sponsored by the government, medical schools, hospitals, employers, labor unions, consumer groups, insurance companies, and hospital-medical plans.

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Home Health Care - Health services rendered in the home to an individual who is confined to the home. Such services are provided to individuals who do not need hospitalization but who need nursing services or therapy, medical supplies and special outpatient services.

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Home Infusion Therapy - Drug therapy rendered in the home to an individual who is confined to the home. Such services are provided to individuals who do not need hospitalization but who need drug therapy that can be safely administered in the home environment.

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Hopsice - A facility that provides palliative and supportive care for terminally ill patients and their families, usually in the home.

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In-Network - The use of health care providers who have contracted with the health plan to provide the medical services for a predetermined rate of reimbursement.

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Integrated Delivery Systems (IDS) - A group of health care services that typically includes hospitals, doctors, other allied health professionals, ambulatory surgical centers, home health agencies, medical equipment companies, pharmacies and ambulance services, long term and rehabilitation care centers, mental health organizations, etc. These groups are designed to be able to take care of all the health needs of a population.

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Managed Care - A system of providing health care through which access, cost and quality are controlled by direct interventions either before, during or after the services are rendered. Managed care organizations use a variety of techniques, such as utilization review, quality assurance programs, and pre-admission certification to better manage the care delivered.

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Medical Service Organization (MSO) - A form of hospital-doctor integration. The MSO provides support services for doctors and usually negotiates with managed care plans on behalf of the hospital and member doctors.

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Member - The term used by third party payors to refer to each individual covered in an insurance plan; includes subscribers and dependents. Frequently, Members are referred to as Covered Lives.

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National Committee on Quality Assurance (NCQA) - A not-for-profit organization that performs quality-oriented accreditation reviews on HMOs and similar types of managed care plans.

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Occupational Therapy - Treatment to restore a physically disabled person's ability to perform activities of daily living such as walking, eating, drinking, dressing, toileting and bathing.

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Orthotics - Science dealing with specialized mechanical devices to support or supplement weakened or abnormal joints or limbs.

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Out-of-Network - The use of health care providers who have not contracted with the health plan to provide the medical services.

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Palliative Care - Relieving or soothing the symptoms of a disease or disorder without effecting a cure.

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Participating Provider - A doctor, hospital, group practice, nurse, nursing home, pharmacy, or other allied health professional or entity that has a direct or indirect contractual arrangement with a managed care group to provide "In-Network" covered services to members.

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Payor (usually Third Party Payor) - The public or private organization that is responsible for payment for health care expenses. Payers may be insurance companies or self-insured employers.

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Physical Therapy - Rehabilitation concerned with the restoration of function and prevention of physical disability following disease, injury or loss of body parts.

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Physician Hospital Organization (PHO) - An entity formed by hospitals and doctors to negotiate contracts with third party payors to provide services under managed care. These organizations may also be involved in managing and overseeing the facility or facilities.

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Point of Service (POS) - The POS is a hybrid that uses a Health Maintenance Organization (HMO) to provide what is now termed in-network care in which a patient usually pays only a co-payment. However, enrollees can seek out-of-network care under the terms of traditional Preferred Provider Organization (PPO) plans with a deductible and percentage coinsurance.

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Precertification - The process of obtaining certification of coverage from a health plan for routine hospital stays, continued hospital stays and outpatient procedures. This process involves reviewing criteria for benefit coverage determination.

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Preferred Provider Organization (PPO) - An insurance plan in which member hospitals and/or doctors contract with a third party payer to deliver services for negotiated fees, usually at a reduced rate.

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Primary Care Physician (PCP) - Provider whose specialty is family practice, internal medicine, pediatrics or obstetrics and/or gynecology.

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Prosthetsis - An artificial device used to replace a missing body part, such as a limb, eye, or a tooth; used fro functional or cosmetic reasons or both.

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Provider - A doctor, hospital, group practice, nurse, nursing home, pharmacy, or other allied health professional or entity that has a direct or indirect contractual arrangement with a managed care group to provide "In-Network" covered services.

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Reinsurance - Assumption by one or more insurers of a portion of the risk accepted by another insurer who has contracted for the entire coverage. It is also called risk control insurance or stop-loss insurance.

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Service Area - The geographical area covered by a network of health care providers.

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Specialist/Specialty Care Physician - Providers whose practices are limited to treating a specific disease (e.g., oncologists), specific parts of the body (e.g., ear, nose and throat), or specific procedures (e.g., oral surgery).

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Speech Therapy - Treatment to correct a speech impairment that resulted from birth or from disease, injury or prior medical treatment.

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Third Party Administrator (TPA) - An organization that provides administrative services including claims processing and underwriting for employers or insurance companies. TPAs are organizations with expertise and capability to administer all or a portion of the claims process. Self-insured employers will often contract with TPAs to handle their insurance functions.

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Utilization Review - A cost-control method used by some insurers and employers to identify and reduce inappropriate and unnecessary care. It is also known as utilization management.

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