1 1 of :17 AM Medical Insurance Guide Medical Necessity form Frequently Asked Questions Glossary of Insurance Terminology Suggestions for contacting your health plan Links to Major Health Insurance Companies and Member Claim Forms 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 5. Appealing a denial 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
2 2 of :17 AM 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 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,
3 3 of :17 AM dentist and/or the anesthesiologist from the OBA practice that will be performing your OBA for your child s dental treatment. Your child s medical condition with your child s exact diagnosis and the symptoms associated with your child s condition. The medical necessity for your child to undergo the dental procedure and the need for office-based anesthesia during this procedure. What health problems could occur if you do not get office-based anesthesia for your child s dental treatment? What other treatments or services you have already had for your child s dental treatment, if any, and why they these other alternative treatments did not allow your child s dental treatment to proceed. 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 This dental procedure is not considered medically necessary Your child is consider too old They do not offer this service under your health plan to any plan participants and office-based anesthesia for pediatric patients is not a covered health benefit under your plan. Whatever the reason for the denial, you have the right to appeal this, and should request details on these steps. 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.
4 4 of :17 AM 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. B. Written Appeal 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.
5 5 of :17 AM 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 or visit their website at for information on how to file a complaint.
6 6 of :17 AM 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:
7 7 of :17 AM (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.
8 8 of :17 AM 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: Always contact them in writing. Phone calls can be made, but written communication is more powerful. Be sure to follow-up all written communications with a phone call to make sure they received your letters. Keep a copy of all your letters for your records. Record all phone calls in a phone log. Keep a log of when, where, and to whom you sent your request. Send important documents by certified mail (return receipt), Federal Express, or by fax with a confirmation sheet. 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
9 9 of :17 AM 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
10 10 of :17 AM 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 Medically necessary 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.
11 11 of :17 AM 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. Preauthorization 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.
12 12 of :17 AM 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 Member Claim Form Aetna https://www.aetna.com/member/ Member Claim Form Cigna Member Claim Form AV Med Member Claim Form United Healthcare Member Claim Form