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| Paid Business |
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Insurance for which the application has been signed, the Medical Examination completed, and the settlement for the Premium tendered.
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| Paid Claims |
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Amounts paid to Providers based on the Health Plan.
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| Paid Claims Loss Ratio |
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Paid Claims divided by total Premiums.
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| Parent Company |
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A company that owns another company.
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| Part D (Medicare Part D) |
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Part D is the Prescription Drug program that became available to allMedicare beneficiaries on January 1, 2006. The Medicare Part D prescription drug program is insurance offered by the federal government and sold through private companies that helps pay for Prescription Drugs.
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| Partial Disability |
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A condition in which, as a result of Injury or Sickness, the Insured cannot perform all of the duties of his occupation but can perform some. Exact definitions vary from Policy to Policy. Also see Permanent Partial Disability and Temporary Partial Disability.
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| Partial Hospital and Day Treatment Behavioral Health Facility or Program |
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See Behavioral Health Facility or Program - Partial Hospital and Day Treatment..
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| Partial Hospitalization Services |
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Additional services provided to mental health or Substance Abuse patients which provides Outpatient treatment as an alternative or follow-up to Inpatient treatment.
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| Participant |
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An employee or former employee who is eligible to receive Benefits from an employee Benefit plan or whose beneficiaries may be eligible to receive Benefits from the plan.
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| Participating Provider |
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Any Health Care Practitioner, facility or supplier, identified for this plan by the Insurance Carrier or the Network Manager, as Participating Provider.
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| Participating Provider Deductible |
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See Deductible - Participating Provider.
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| Participating Provider Network |
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The group of Participating Providers within the Health Care Provider Network, identified for this plan by the Insurance Carrier or the Network Manager, who have agreed to accept a Contracted Rate as payment in full for specific treatment, services or supplies. This list is subject to change at any time without notice.
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| Participating Provider Out-of-Pocket Limit |
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See Out-of-Pocket Limit - Participating Provider.
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| Participation |
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The number of employees enrolled compared to the total number eligible for Coverage. Many times, a minimum Participation percentage is required.
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| Patient Bill Of Rights |
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Refers to the Consumer Bill of Rights and Responsibilities, a report prepared by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry in an effort to ensure the security of patient information, promote Healthcare Quality, and improve the availability of healthcare treatment and services. The report lists a number "rights," subdivided into eight general areas, that all healthcare consumers should be guaranteed and describes responsibilities that consumers need to accept for the sake of their own health.
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| Patient Perception |
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A type of outcomes measure related to how the patient feels after treatment.
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| PBM Plan |
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See Pharmacy Benefit Management (PBM) Plan.
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| PCCM |
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See Primary Care Case Manager (PCCM).
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| PCP |
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A Primary Care Physician (PCP) you choose from a plan Network to provide your routine and Preventive Care. HMOs require you to select a PCP, while PPOs don't. However, if you select a PCP with your PPO plan, you'll have a lower Copay for Office Visits. Also see Primary Care Provider (PCP).
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| PDP |
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Stand-alone Medicare Part D Prescription Drug Plans (PDPs) provide reduced-cost Prescription Drug Coverage toMedicare beneficiaries. Medicare Part D plans work together with Medicare Part A and Medicare Part B, as well as Medicare Supplements andMedicare Advantage (MA) plans that do not provide Prescription Drug Coverage. The Annual Enrollment Period (AEP) for PDPs run from Nov 15 through Dec. 31, with January 1 as the plan starting date.
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| Peer Review |
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The analysis of a clinician's care by a group of that clinician's professional colleagues. The Provider's care is generally compared to applicable standards of care, and the group's analysis is used as a learning tool for the members of the group.
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| Peer Review Organizations (PROs) |
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According to the Balanced Budget Act of 1997, organizations or groups of practicing physicians and other healthcare professionals paid by the federal government to review and evaluate the services provided by other practitioners and to monitor the Quality of care given toMedicare patients.
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| Penalties |
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Medicare Beneficiary without Creditable Coverage who were eligible to enroll but waited until after May 15, 2006, may pay the standard monthly Premium plus a 1-percent penalty of the Base Beneficiary Premium per month - or 12 percent a year - and won't be able to enroll until the next Annual Election Period (November 15, through December 31 of each year). This higher Premium will stay with them for as long as they are enrolled in the program. People who turn 65 between Annual Enrollment Period (AEP)s (AEP) can join a Medicare Prescription Drug Plan as soon as they sign up for Medicare. They can enroll at any time three months before or three months after their Medicare Eligibility Date without penalty. The Effective Date of prescription drug coverage will begin on their Medicare Eligibility Date. If they don't join a plan within three months after their Medicare Eligibility Date don't have Creditable Coverage and decide to join later, they'll pay the same 1-percent penalty.
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| Pended |
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A Claims term that refers to a situation in which it is not known whether an authorization has or will be issued for delivery of a healthcare service, and the case has been set aside for review.
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| Percentage Participation |
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A provision in a Health Insurance (HI) contract which states that the insurer will share losses in an agreed proportion with the Insured. An example would be an 80-20 Participation where the insurer pays 80% and the Insured pays the 20% of losses covered under the contract. Often erroneously referred to as Coinsurance.
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| Performance Measures |
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Quantitative measures of the Quality of care provided by a Health Plan or Provider that consumers, payors, regulators, and others can use to compare the plan or Provider to other plans and Providers.
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| Period of Confinement |
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The initial and subsequent Inpatient stays resulting from the same or a related Sickness or Injury and/or any complications unless the current Inpatient stay begins more than 30 days after the date of discharge from the most recent Inpatient stay.
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| Permanent and Total Disability |
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A Total Disability from which the Insured does not recover. When used as a definition in a Policy (usually a life insurance policy Rider), "permanent" is presumed after a stated period of time, commonly six months.
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| Permanent Insurance |
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Coverage that can be continued relatively indefinitely (such as to age 65 for most permanent Health Insurance (HI) policies) as long as the Policyholder makes scheduled Premium payments and refrains from actions that would invalidate the Policy (such as Misrepresentations on the application)
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| Permanent Partial Disability |
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A condition where the injured party's earning capacity is impaired for life, but he is able to work at reduced efficiency.
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| Permanent Total Disability |
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A condition where the injured party is not able to work at any gainful employment for the remaining lifetime.
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| Personal Care Physician |
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See Primary Care Provider (PCP).
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| Personal Care Provider |
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See Primary Care Provider (PCP).
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| Personal Medical Equipment |
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Equipment, such as a prosthesis, that meets all of the following:
1. Is designed for and able to withstand repeated use; and
2. Is primarily and customarily provided to serve a medical purpose; and
3. Is not intended for use by successive patients.
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| Pharmaceutical Cards |
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Identification Cards issued by a Pharmacy Benefit Management (PBM) Plan to plan members. These cards assist PBMs in processing and tracking pharmaceutical Claims. Also known as Drug Cards or Prescription Cards.
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| Pharmacy And Therapeutics Committee |
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Committee charged with developing a Formulary, reviewing changes to that Formulary, and reviewing abnormal prescription Utilization patterns by Providers.
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| Pharmacy Benefit Management Plan (PBM) |
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A type of Managed Care specialty service organization that seeks to contain the costs, while promoting safer and more efficient use, of Prescription Drugs or pharmaceuticals. Also known as a Prescription Benefit Management Plan.
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| Pharmacy Network |
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This is the group of pharmacies who have contracted with the PDP to save you money on prescriptions.
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| PHO |
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See Physician-Hospital Organization (PHO).
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| Physical Medicine |
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Treatment of physical conditions relating to bone, muscle or neuromuscular pathology. This treatment focuses on restoring function using mechanical or other physical methods.
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| Physical Therapist |
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A trained medical person who provides rehabilitative services and therapy to help restore bodily functions such as walking, speech, the use of limbs, etc.
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| Physical Therapy |
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The treatment of a Sickness or an Injury, by a Health Care Practitioner who is a Physical Therapist, using therapeutic exercise and other services that focus on improving posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility, functional activities of daily living and alleviating pain.
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| Physician Contingency Reserve (PCR) |
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A portion of the Claim which is deducted and withheld by the Health Plan before payment is made to the physician. It serves as an incentive for proper Quality and Utilization of health care. A portion of this reserve may be returned to the physician or to pay claims where the plan needs additional funds. It is also sometimes called "withhold."
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| Physician Practice Management (PPM) Company |
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A company, owned by a group of investors, that purchases physicians' practice assets, provides practice management services, and, in most cases, gives physicians a long-term contract to continue working in their practice and sometimes an equity (ownership) position in the company.
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| Physician Profiling |
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n the context of a pharmacy Benefit plan, the process of compiling data on physician prescribing patterns and comparing physicians' actual prescribing patterns to expected patterns within select drug categories. Also known as Profiling.
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| Physician, Competent Medical Authority |
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means an individual who is qualified to perform or prescribe surgical or manipulative treatment. A Physician must be recognized (licensed and chartered) by the state or country in which he or she is practicing, cannot be a relative of the Insured and must practice within the scope of his or her license. Treatment of an Accident must be within the knowledge or expertise of the Physician.
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| Physician-Hospital Organization (PHO) |
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A Joint Venture between a Hospital and many or all of its Admitting Physician s whose primary purpose is contract negotiations with MCOs and marketing.
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| Physician's Current Procedural Terminology (CPT) |
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This terminology includes medical services and procedures performed by physicians and other Providers of health care. The health care industry uses it as a standard for describing services and procedures.
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| Place of Service |
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This designates where the actual Health Services are being performed, whether it be home, hospital, office, clinic, etc.
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| Plan Funding |
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The method that an employer or other payor or purchaser uses to pay medical Benefit costs and administrative expenses.
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| Point-Of-Service (Pos) Product |
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A healthcare option that allows Members to choose at the time medical services are needed whether they will go to a Provider within the plan's Network or seek medical care outside the Network.
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| Point-of-Service Plan |
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This plan allows a choice of whether to receive services from a Participating Provider or Nonparticipating Provider.
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| Policy |
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The Group master contract issued by the Insurance Carrier to the Policyholder providing Benefits for Covered Persons.
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| Policy Owner |
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The parent or legal guardian who signs the Enrollment form for Coverage under this plan when only minor children are Covered Persons.
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| Policy Year |
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The twelve month period beginning with the Effective Date or Renewal date of the Policy.
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| Policyholder |
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The person or party who owns an individual insurance Policy. This person may be the Insured, a relative, the beneficiary, a Corporation, or another person.
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| Pool (Risk Pool) |
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A separate account which includes entries for income and expenses. It is used when a number of groups are put together for the purposes of combining their Premium and paying their losses.
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| Pooling |
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The practice of Underwriting a number of Small Groups as if they constituted one Large Group.
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| Portability |
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The ability for an individual to transfer from one health insurer to another health insurer with regard to a Pre-Existing Condition - Long Answer or other Risk factors
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| POS Product |
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See Point-Of-Service (Pos) Product.
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| PPA |
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See Preferred Provider Arrangement (PPA).
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| PPM Company |
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See Physician Practice Management (PPM) Company.
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| PPO |
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A Preferred Provider Organization (PPO) that provides access to a Network of doctors and Hospitals that coordinate your care. This allows you to get more Benefits than the Original Medicare Plan and many Medicare Supplement plans. PPOs also allow you to use any doctor or Hospital outside of the Network for a higher Copay or Coinsurance. Also see Preferred Provider Organization (PPO).
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| Practical Nurse |
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A licensed individual who provides custodial type care such as help in walking, bathing, feeding, etc. Practical nurses do not administer medication or perform other medically related services.
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| Practice Guideline |
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See Clinical Practice Guideline.
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| Pre-Admission Authorization |
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A cost containment feature of many Group medical policies whereby the Insured must contact the insurer prior to a hospitalization and receive authorization for the admission.
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| Pre-Admission Certification |
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Before being admitted as an Inpatient in a hospital, certain criteria are used to determine whether the Inpatient Care is necessary.
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| Pre-Admission Review |
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A review of an individual's health care status or condition, prior to an individual being admitted to a Hospital or Inpatient health care facility. 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.
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| Pre-Admission Testing |
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Medical tests that are completed for an individual prior to being admitted to a Hospital or Inpatient health care facility
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| Pre-Authorization |
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Under a Pre-Authorization provision of a Health Insurance (HI) Policy, the Insured must contact the Health Insurance (HI) company prior to a hospitalization or surgery, and receive authorization for the service.
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| Pre-Certification |
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This is a requirement that a insured person call their Health Insurance (HI) company and advise them a doctor has stated certain medical treatment is required. This is done before receiving treatment from the doctor or Hospital. A Health Insurance (HI) Policy will normally list the medical conditions that require Pre-Certification before receiving treatment. When pre-certification is not received, Benefits will be reduced or possibly not covered. Also see prospective authroization.
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| Pre-Existing Condition - Long Answer |
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A Sickness or an Injury and related complications:
1. For which medical advice, consultation, Diagnosis, care or treatment was sought, received or recommended from a Provider or Prescription Drugs were prescribed during the 12-month period immediately prior to the Covered Person's Effective Date, regardless of whether the condition was diagnosed, misdiagnosed or not diagnosed; or
2. That produced signs or symptoms during the 12-mongh period immediately prior to the Covered Person's Effective Date.
The signs or Symptoms were significant enough to establish manifestation or onset by one of the following test:
a. The signs or symptoms reasonably should have allowed or would have allowed one learned in medicine to diagnose the condition; or
b. The signs or symptoms reasonably should have caused or would have caused an ordinarily prudent person to seek diagnosis or treatment.
A pregnancy that exists on the day before the Covered Person's Effective Date will be considered a Pre-Existing Condition.
In the event You have previously had breast cancer but have since been determined to be free of breast cancer, routine follow-up care to determine a recurrence of breast cancer does not constitute medical treatment, Diagnosis, or consultation for purposes of determining a Pre-Existing condition unless evidence of breast cancer is found during or as a result of the follow-up care.
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| Pre-existing Condition - Short Answer |
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A health problem that existed before the date your insurance became effective. Each Health Insurance (HI) company uses its own particular definitions of pre-existing condition. However, the following statement is in line with most insurance company provisions: "A pre-existing condition is a medical condition that would cause a normally prudent person to seek treatment during the twelve months prior to the beginning of Coverage." See a more detailed Pre-Existing Condition - Long Answer definition.
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| Pre-Existing Conditions - AD&D |
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are physical, mental or chemical conditions which arise from any Accident which was: 1) not disclosed on the application, and 2) for which You sought any medical advice or treatment prior to the Effective Date of this insurance or which caused symptoms for which an ordinarily prudent person would have sought medical advice.
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| Preferred Brand Drugs |
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Among Brand drugs, these are the ones the plan prefers, so they are less costly. These Brand drugs generally have lower co-pays than Non-Preferred Brand-Name Drugs.
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| Preferred Provider Arrangement (PPA) |
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As defined in state laws, a contract between a healthcare insurer and a Health Care Provider or group of Providers who agree to provide services to persons covered under the contract. Examples include Preferred Provider Organization (PPO) and Exclusive Provider Organization (EPO).
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| Preferred Provider Organization (PPO) |
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A Network of Health Care Providers with which a health insurer has negotiated contracts for its insured population to receive Health Services at discounted costs. Health care decisions generally remain with the patient as he or she selects Providers and determines his or her own need for services. Patients have financial incentives to select Providers within the PPO Network.
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| Pregnancy Care |
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Federal maternity legislation, enacted in 1978, requires that employers engaged in interstate commerce who have 15 or more employees provide the same Benefits for pregnancy, childbirth, and related medical conditions as for any other Sickness or Injury.
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| Premium |
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A prepaid payment or series of payments made to a Health Plan by purchasers, and often plan members, for medical Benefits.
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| Premium Taxes |
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State income taxes levied on an insurer's Premium income.
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| Prepaid Care |
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Healthcare services provided to an HMO Member in Exchange for a fixed, monthly Premium paid in advance of the delivery of medical care.
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| Prepaid Group Practices |
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Term originally used to describe healthcare systems that later became known as Health Maintenance Organization (HMO).
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| Prescription Benefit Management Plan |
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See Pharmacy Benefit Management (PBM) Plan.
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| Prescription Cards |
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See Pharmaceutical Cards.
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| Prescription Drug |
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Any medication that:
1. Has been fully approved by the Food and Drug Administration (FDA) for marketing in the United States; and
2. Can be legally dispensed only with the written Outpatient Rx - Prescription Order of a Health Care Practitioner in accordance with applicable state and federal laws; and
3. Contains the legend wording: "Caution: Federal Law Prohibits Dispensing Without Prescription" or "RX Only" on the manufacturer's label, or similar wording as designated by the FDA.
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| Prescription Medication |
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A drug which can be dispensed only by prescription and which has been approved by the Food and Drug Administration (FDA).
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| Presumptive Disability |
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A disability involving loss of sight, hearing, speech, or any two limbs, which is presumed to be a Permanent and Total Disability. In such cases, the insurer does not require the Insured to submit to periodic Medical Examinations to prove continuing disability.
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| Preventive Care |
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An approach to health care which emphasizes preventive measures and health screenings such as routine physicals, Well-Baby Care, immunizations, diagnostic lab and x-ray tests, pap smears, mammograms and other early detection testing. The purpose of offering Coverage for Preventive Care is to diagnose a problem early, when it is less costly to treat, rather than late in the stage of a disease when it is much more expensive, or too late to treat.
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| Primary Care |
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General medical care that is provided directly to a patient without Referral from another physician. It is focused on preventative care and the treatment of routine injuries and illnesses.
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| Primary Care Case Manager (PCCM) |
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In states that have obtained a Section 1915(b) Waiver, a Primary Care Provider (PCP) who contracts directly with the state to provide Case Management services, such as coordination and delivery of services, toMedicaid patients in an effort to reduce Emergency Room use, increase Preventive Care, and improve overall effectiveness by fostering a close physician-patient relationship.
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| Primary Care Network (PCN) |
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This is a group of Primary Care Physician (PCP)s who provide care to those Members of a particular Health Plan.
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| Primary Care Physician (PCP) |
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Under a Health Maintenance Organization (HMO) plan, the Primary Care physician is usually an insured person's first contact for health care. This is often a family physician, internist, or pediatrician. A Primary Care physician monitors patient health, treats most patient health problems, and refers patients, if necessary, to specialists.
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| Primary Care Provider (PCP) |
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A physician or other medical professional who serves as a Group member's first contact with a plan's healthcare system. Also known as a Primary Care Physician (PCP), Personal Care Physician, or Personal Care Provider.
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| Primary Coverage |
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This is the Coverage which pays expenses first, without consideration whether or not there is any other Coverage. See also Coordination of Benefits (COB).
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| Primary Source Verification |
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A process through which an organization validates Credentialing information from the organization that originally conferred or issued the Credentialing element to the practitioner.
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| Principal Sum |
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means the lump sum Benefit payable in the event of a loss that stipulated a Principal Sum amount.
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