Benefits are specific areas of Plan coverage’s, i.e., outpatient visits, hospitalization and so forth, that make up the range of medical services that an employer offers its employees. Also, a contractual agreement, specified in a Certificate of Coverage, determining covered services provided by insurers to members.

CAQH (Council for Affordable Quality Healthcare)

CAQH allows for a streamlined, consistent, online credentialing process that provides providers an easy tool to update their credentials and information, so groups can review for participation.


A method of paying medical providers through a pre-paid, flat monthly fee for each covered person. The payment is independent of the number of services received or the costs incurred by a provider in furnishing those services.

Case Management

The monitoring and coordination of treatment rendered to patients with specific diagnosis or requiring high-cost or extensive services. The process by which all health-related matters of a case are managed by a physician or nurse or designated health professional. Case management is intended to ensure continuity of services and accessibility to overcome rigidity, fragmented services, and the mis-utilization of facilities and resources. It also attempts to match the appropriate intensity of services with the patient’s needs over time.


The protection of individually identifiable information as required by state or federal law or by policy of the healthcare provider.

Contracted Provider

Any hospital, physician, skilled nursing facility, extended care facility, individual, organization, or agency licensed that has a contractual arrangement with an HMO or medical group for the provision of services under an insurance contract.

Co-Payment; Copay

A cost sharing arrangement in which a person pays a specific charge for a specific medical service — say $50 for an office visit or $20 for a prescription.

Covered Benefit

A medically necessary service that is specifically provided for under the provisions of a Certificate of Coverage. A covered benefit must always be medically necessary, but not every medically necessary service is a covered benefit. For example, some elements of custodial or maintenance care, which are excluded from coverage, may be medically necessary, but are not covered.

No terms available at this time.

Effective Date

The date on which a policy’s coverage goes into effect.


Sudden unexpected onset of illness or injury which requires the immediate care and attention of a qualified physician, and which, if not treated immediately, would jeopardize or impair the health of the Member.


A contact between an individual and the health care system for a health care service or set of services related to one or more medical conditions.

Encounter Data

Data relating to treatment or service rendered by a provider to a patient, regardless of whether the provider was reimbursed on a capitated or fee-for-service basis. Sometime this data is used in determining the level of service.


Any person eligible as either a subscriber or a dependent for service in accordance with a contract. The same as beneficiary, individual, or member of a health plan.


Specific conditions or circumstances for which the policy will not provide benefits.


A payment system for health care where the provider is paid for each service rendered.


Most HMOs rely on the primary care physician, or “gatekeeper,” to screen patients seeking medical care and effectively eliminate costly and sometimes needless referrals to specialists for diagnosis and management. The gatekeeper is responsible for the administration of the patient’s treatment and must coordinate and authorize all medical services, laboratory studies, specialty referrals, and hospitalizations. If an enrollee visits a specialist without prior authorization from his or her designated primary care physician, the medical services delivered by the specialist will have to paid in full by the patient.

Generic Drug/Prescription Substitution

Drug manufacturers produce generic versions of the original branded product. The generic version of the drug (which is theorized to be the exact same product manufactured by a different firm) is dispensed even though the original product is prescribed. Most HMO prescription programs offer a full range of generic substitution because of the generally lower cost of generic products.


A physician who specializes in treating diseases of the female reproductive organs and providing well-woman health care that focuses primarily on the reproductive organs.

Health Maintenance Organization (HMO)

Prepaid health plans in which you pay a monthly premium and the HMO covers your office visits, hospital stays, emergency care, surgery, preventive care, checkups, lab tests, X-rays, and therapy. You will pay a pre-determined copayment amount for each service (e.g., $20 for an office visit or $50 for an emergency room visit). You must choose a primary care physician who coordinates all of your care and makes referrals to any specialists you might need. In an HMO, you must use the doctors, hospitals and clinics that participate in your plan’s network.


Work by stimulating the immune system, the natural disease-fighting system of the body. The healthy immune system is able to recognize invading bacteria and viruses and produce substances (antibodies) to destroy or disable them. Immunizations prepare the immune system to ward off a disease.

No terms available at this time.

No terms available at this time.

No terms available at this time.

Managed Care

An organized way to manage costs, use, and quality of the health care system. The major types of managed care plans are health maintenance organizations (HMOs), point-of-service (POS) plans and preferred provider organizations (PPO).


A joint federal-state health insurance program that is run by the states and covers certain low-income and disabled people.

Medical Necessity; Medically Necessary Services

Services or supplies which meet the following requirements: They are appropriate and necessary for the symptoms, diagnosis, or treatment of the medical condition; They are provided for the diagnosis or direct care and treatment of the medical condition; They meet the standards of good medical practice within the medical community in the service area; They are not primarily for the convenience of the plan member or a plan provider; and They are the most appropriate level or supply of service which can safely be provided.


The federally sponsored health insurance program of hospital and medical insurance, primarily for people age 65 and over.

Minimum Necessary

A HIPAA Privacy Rule standard requiring that when protected health information is used or disclosed, only the information that is needed for the immediate use or disclosure should be made available by the health care provider or other covered entity. This standard does not apply to uses and disclosures for treatment purposes (so as not to interfere with treatment) or to uses and disclosures that an individual has authorized, among other limited exceptions.


An affiliation of providers through formal and informal contracts and agreements. Networks may contract externally to obtain administrative and financial services. A list of physicians, hospitals and other providers who provide health care services to the beneficiaries of a specific medical group.


A physician who specializes in the surgical care of women and their children during pregnancy, childbirth and post-natal care.

Out of Area Care

Covered benefits supplied to a patient by a payer or managed care organization when the patient needs services while outside the geographic area of the network.

Out of Network Benefits

With most HMOs, a patient cannot have any services reimbursed if provided by a hospital or doctor who is not in the network.

Out-of-Network Provider

A health care provider with whom a managed care organization has not pre-authorized and does not have a contract to provide health care services. The beneficiary must pay for the costs of care from an out-of-network provider.

Out-of-Pocket Maximum

The most money you will be required to pay in a year for copayments and coinsurance for covered expenses. It is a stated dollar amount set by the insurance company, in addition to regular premiums.

Outpatient Care

Care given a person who is not bedridden; also called ambulatory care. Many surgeries and treatments are provided on an outpatient basis.

Participating Provider

A provider who has signed an agreement with the HMO and/or UPN to accept its payment for covered services as payment in full, less any deductible or copayment that applies. Thorough communication of exam findings, medical services and treatment plans makes coordinating services quick.

Preadmission Review, Pre-Admission Certification, Pre-Certification, or Pre-Authorization

Review of “need” for inpatient care or other care before admission. This is a method of evaluating the need for service prior to the service being rendered. The practice of reviewing patient medical information using nationally certified clinical criteria for inpatient admission prior to the patient entering the hospital in order to assure that the admission is medically necessary. The process of notification and coordination of elective inpatient admission and identified outpatient services before the service is rendered. An administrative procedure whereby a health provider submits a treatment plan to the medical group before treatment is initiated. The treatment plan will confirm patient’s eligibility, covered service, co-payment factors and maximums before application of clinical protocol to confirm medical necessity, appropriateness of care plan and even discharge plans.

Preventive Care

Health care emphasizing priorities for prevention, early detection, and early treatment of conditions, generally including routine physical examination, immunization, and well-person care. Age appropriate screenings include breast, cervical and colon cancer tests.

Primary Care Physician

Basic or general health care usually rendered by general practitioners, family practitioners, internists, obstetricians and pediatricians — who are often referred to as primary care practitioners or PCPs. This provider serves as the initial interface between the member and the medical care system. The PCP is usually a physician, selected by the member upon enrollment, who is trained in one of the primary care specialties who treats and is responsible for coordinating the treatment of members assigned to his/her plan. Also, see Gatekeeper.

Provider Network

A collection of clinical persons (for example; doctors, nurses) or institutions (for example; hospital, clinic, laboratory) under contract with UPN that offer a covered service. People enrolled with UPN will have referral access to this preferred provider network (except in specific situations) to make sure services are not stopped, disrupted, or suspended.

No terms available at this time.


The process of sending a patient from one network practitioner to another for health care services. A written order from the enrollee’s primary care physician (PCP) is required for the enrollee to see a specialist or get certain services. An enrollee must get a referral before the enrollee can get care from anyone except the PCP. Without a formal referral, the plan may not pay for the care.


Providers, whose practices are limited to a specific disease, part of the body, age group, or procedure. UPN Specialists are Board-certified in their particular field of medicine.

Third-Party Payer

Any payer of health care services other than you. This can be an insurance company, an HMO, a PPO, or the federal government.

Utilization Review

The critical examination (as by a physician or nurse) of health-care services provided to patients especially for the purpose of monitoring the quality of care, managing care within a defined preferred network of providers, and identifying potentially unnecessary medical procedures.


Injection of a killed microbe in order to stimulate the immune system against the microbe, thereby preventing disease. Vaccinations work by stimulating the immune system, the natural disease-fighting system of the body. In addition to the initial immunization process, it has been found that the effectiveness of immunizations can be improved by periodic repeat injections or “boosters.”


A health care process that fosters awareness and attitudes toward healthy lifestyles so that individuals can make informed choices to achieve optimum physical and mental health.

No terms available at this time.

No terms available at this time.

No terms available at this time.