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A

• A&S

  • Accident and Sickness

• AAD

  • Annual Aggregate Deductible

• Accident & Sickness

  • Coverage for short-term income replacement when the covered person is disabled because of an accident or illness. Same as weekly indemnity, weekly disability, and short-term disability

• Accidental Death and Dismemberment

  • Insurance providing a benefit if the insured person dies by accidental means or accidentally loses certain specified body parts (leg, arm, etc.).

• Actively-At-Work

  • A contract provision that provides that the coverage will only be available for employees actively at work on a full time basis, on the effective date of the coverage. Those not actively at work become eligible upon their return. The matching provision for dependant is often a non-hospital-confined provision.

• Acupuncture

  • Chinese medical practice that treats illness or provides local anesthesia by the insertion of needles at specified sites of the body.

• AD&D

  • Accidental Death & Dismemberment:   Insurance providing a benefit if the injured person dies by accidental means or accidentally loses certain specified body parts (leg, arm, etc.).

• Adjudication

  • The process used by health plans to determine the amount of payment for a claim.

• Administrative Services Only

  • An arrangement under which an insurance company, for a fee, processes claims and handles paperwork for a self-funded group. This frequently includes all insurance company services (actuarial services, underwriting, benefit description, etc.) except assumption of risk.

• Aggregate Attachment Point

  • See Annual Aggregate Deductible.

• Aggregate Factor

  • A number that is multiplied by the number of covered persons each month during a contract period to calculate the annual aggregate deductible (ADD). It includes anticipated claims plus margin.

• Aggregate Stop Loss

  • The form of excess risk coverage which provides protection for the employer against the accumulation of claims exceeding a stated level. This is protection against abnormal frequency of claims in total rather than abnormal severity of a single claim.

• Allergy Treatment

  • Treatment given to prevent an overreaction of the immune system to a previously encountered, ordinarily harmless substance, resulting in a skin rash, swelling of mucous membranes, sneezing or wheezing, or other abnormal conditions.

• Allowable Charge

  • The maximum fee that a health plan will reimburse a provider for a given service.

• Ambulatory Services

  • Health care services provided to patients who have not been admitted to a hospital. Settings for this type of care include a doctor's office, a free standing facility or a hospital outpatient facility or clinic.

• Ambulatory Surgery

  • Surgical procedures performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called Outpatient Surgery.

• Annual Aggregate Deductible

  • This number represents the overall limit of claim liability for the group.  Beyond this point the Stop Loss policy indemnifies the group at the end of the contract period. Also called the trigger point or attachment point. See also Loss Fund.

• Appeals

  • A process used by a patient to request that the health plan reconsider a previous authorization or claim decision.

• ASO

  • Administrative Services Only

• Attachment Point

  • See Annual Aggregate Deductible

• Authorization

  • See Pre-Authorization.

B                                                   (index)

• Benefit

  • Payments provided for covered services under the terms of the policy. The benefits may be paid to the insured, or on his behalf, to the medical provider. Benefit design includes the types of benefits offered, limits e.g., number of visits, percentage paid or dollar maximums applied, subscriber responsibility (cost sharing components), subscriber incentives to use network providers.

• Benefit Office

  • The location or agency that processes claims, and from which a provider or patient may receive benefits and eligibility information.

• Benefit Period

  • The maximum length of time for which benefits will be paid.

• Benefit Plan Summary

  • The description of employee benefits required to be distributed to the employees by ERISA. A synopsis of the benefits, usually in simple language, which does not include all the details of the plan.

• Blues

  • Blue Cross Blue Shield Insurance Companies

• Brand Name Drug

  • A prescription drug that has been patented and is only available through one manufacturer.

• Broker

  • The licensed producer representing the client who negotiates the program with the insurer and TPA.

C                                       (index)

• Careers

  • Is where future employment with AssureCare can be found. An equal opportunity employer that offers competitive compensation and full benefits.

• Case Management

  • A clinical and administrative process in which proactive, individualized, and cost effective health care services are identified, coordinated, implemented, and evaluated on an ongoing basis for individuals who have sustained an injury or illness. AssureCare offers a Case Management program that identifies cases with a high potential for extended days and provides case management services if authorized by the payer to do so. This potential is suggested by the following factors: Designated diagnosis codes; Re-admission within 6 months;  Length of stay more than 15 days;  Subjective identification by nurse reviewer

• Certification

  • See Pre-authorization

• Chemotherapy

  • Treatment of malignant disease by chemical or biological anti-neoplastic agents.

• Chiropractic Care

  • An alternative medicine therapy administered by a licensed Chiropractor. The Chiropractor adjusts the spine and joints to treat pain and improve general health.

• Claim

  • A request for payment for benefits received or services rendered.

• Clients

  • Companies or organizations that have purchased AssureCare products or services.

• COB

  • Coordination of Benefits

• COBRA

  • (Consolidated Omnibus Budget Reconciliation Act) Legislation relative to mandated benefits for all types of employee benefit plans. The most significant aspects within this legislation are the requirements for continued coverage for employees and/or their dependants who would otherwise lose coverage for 18 months (36 months for dependants in the event of the employee's death).

• Coinsurance

  • An arrangement under which the insured person pays a fixed percentage of the cost of medical care after the deductible has been paid. For example, a health plan might pay 80% of the allowable charge, with the enrollee responsible for the remaining 20%; the 20% amount is then referred to as the coinsurance amount.

• Coinsurance maximum

  • Once the deductible has been met on the insured's health insurance, they will be responsible for paying a certain percentage of their covered services. A limit has been set on the total coinsurance amount they are responsible to pay during the calendar year.

• Contact Us

  • Page where you can locate and contact one of our available departments that can help you.

• Continuation

  • Extension of insurance.

• Contraception

  • Means of avoiding pregnancy.

• Contract

  • A legal agreement between an individual subscriber or an employer group and a health plan that describes the benefits and limitations of the coverage. One subscriber could have two contracts (policies) - one for health and one for dental. Can also be called a Benefit Certificate or Policy.

• Contract Holder

  • See Subscriber.

• Conventional Funding

  • Fully insured plans. Typically premiums are paid monthly in advance and experience refunds may or may not be part of the policy provisions.

• Conversion

  • An individual health policy issued to an employee or dependant leaving the group. The conversion policy is issued without regard to pre-existing conditions at appropriate rates. The benefits are generally very limited.

• Conversion Option

  • The exercise of an option to purchase individual coverage at a negotiated rate by a person who is leaving an employee group, typically at retirement.

• Coordination of Benefits

  • The contract provision that prevents a claimant from profiting by collecting from two different group plans such that the total is greater than actual expenses. COB provisions provide for primary and secondary status for the various plans involved and seek to guarantee that the total paid by all will not exceed 100% of the out-of-pocket expenses of the claimant.

• Coordination of Benefits (COB)

  • The provision which applies when an enrollee is covered by two health plans at the same time. The provision is designed so that the payments of both plans do not exceed 100% of the covered charges. The provision also designates the order in which the multiple health plans are to pay benefits. Under a COB provision, one plan is determined to be primary and its benefits are applied to the claim first. The unpaid balance is usually paid by the secondary plan to the limit of its responsibility. Benefits are thus "coordinated" between the two health plans.

• Co-payment (or co-pay)

  • A way in which the enrollee shares in the cost of health care. The benefit plan requires the enrollee to pay a flat dollar amount per unit of service. A common example of a co-pay is $10 per physician office visit.

• Cost Containment

  • Features in the plan of benefits or in the administration of the plan designed to reduce or eliminate certain charges to the plan such as unnecessary surgery or hospital days thus improving the plans loss experience. Items labeled cost containment features include second surgical opinion, outpatient surgery, hospital bill audit, hospital pre-admission certification, length of stay review, discharge planning, and large case management.

• Cost Plus

  • A method of administering claims only, by either an insurer or Blue plan.  Similar in result to ASO, Cost Plus is often used by entities such as health care contractors that cannot issue ASO agreements.

• Covered Employee

  • A person meeting the definition of eligibility in the employer's plan document.

• Covered Services

  • Hospital, medical, and other health care services incurred by the enrollee that are entitled to a payment of benefits under a health benefit contract. The term defines the type and amount of expense, which will be considered in the calculation of benefits.

• Custodial Care

  • Care that is provided primarily to meet the personal needs of the patient. Such care includes help in walking, bathing or dressing. It may also includes preparing food, or assistance with special diets, administering medicine or any other care that does not require continuous services of medical-trained personnel.

• Customary and Reasonable (C&R)

  • The amount customarily charged for the service by other physicians in the area (often defined as a specific percentile of all charges in the community), and the reasonable cost of services for a given patient after medical review of the case. Also called "Usual, Customary and Reasonable" (UCR).

D                                                  (index)  

• Day Treatment Center

  • An outpatient psychiatric facility that is licensed to provide outpatient care and treatment of mental or nervous disorders or substance abuse under the supervision of physicians.

• Deductible

  • An amount the insured person must pay for covered services during a calendar year, January 1 through December 31, before health benefit payments begin.

• Dental Care

  • Procedures performed on the teeth in a dentist's office.

• Dependent

  • Person (spouse or child) other than the subscriber who is covered in the subscriber's benefit certificate. Also called a "Member" or "Beneficiary".

• Deposit Premium

  • The amount required in order to place a Stop Loss policy in force; generally the first month's premium.

• Diagnostic Tests

  • Tests and procedures ordered by a physician to determine if the patient has a certain condition or disease based upon specific signs or symptoms demonstrated by the patient. Such diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory, pathology services or tests.

• DRG

  • Diagnostic Related Groups.  A prospective payment system that pays a set amount for a given diagnosis.

• Drug Formulary

  • A list of preferred pharmaceutical products that health plans, working with pharmacists and physicians, have developed to encourage greater efficiency in the dispensing of prescription drugs without sacrificing quality.

• Durable Medical Equipment (DME)

  • Mechanical devices, equipment and supplies that enable a person to maintain functional ability. Also called Medical Equipment.

E                                                  (index) 

• Effective Date

  • The date on which the coverage of an insurance policy goes into effect at 1201 a.m.

• Emergency Care

  • (Refer to "what each plan calls emergency care") Care for patients with severe or life-threatening conditions that require immediate intervention.

• Enrollee

  • An individual who is enrolled and eligible for coverage under a health plan contract. Also called "Member".

• ERISA

  • Employment Retirement Income Security Act of 1974 ... the basis of most employee benefit legislation. Even new laws and changes are normally designed as amendments to ERISA. This federal legislation allows for and sets guidelines regarding a group's ability to self-fund their benefits.

• Excess Loss Coverage/Insurance

  • See Stop Loss Coverage

• Excess Risk

  • See Stop Loss Coverage

• Exclusions

  • Specific conditions or circumstances that are not covered under the benefit agreement. It is very important to consult the benefit contract to understand what services are not covered benefits.

• Expected Paid Claims

  • An estimate of the dollar value of claims to be paid during a contract period.

• Experience Period

  • An historical period with specific beginning and ending points for which paid claims and covered employees are known. To have a complete understanding of the experience period, it is also necessary to know what the plan design was, whether it was the first or a subsequent contract period with that carrier, rates (with effective dates), paid premiums, and any other bits of information about who incurred the claims and how they were paid.

• Experimental Procedures

  • Procedures that are mainly limited to laboratory research.

• Expiration Date

  • The date indicated in an insurance contract as the date coverage expires.

• Explanation of Benefits (EOB)

  • A form sent to the enrollee after a claim for payment has been processed by the health plan. The form explains the action taken on that claim. This explanation usually includes the amount paid, the benefits available, reasons for denying payment, or the claims appeal process

• Extended Benefits

  • Some plans provide for extension of benefits for a set period of time to disabled persons beyond the termination of coverage under the plan. Benefits are provided only for the disabling condition and require continuous disability.

F                                   (index)

• FAQ

  • Frequently Asked Questions

• Final Enrollment

  • A complete listing of employees covered on the effective date of coverage.  They must be eligible by the definition established in the plan document.

• Final Underwriting

  • A review of quoted rates and factors upon receipt of requested additional documents data to firm up a conditional offer.

• Form 5500

  • The annual filing form for ERISA for all plans with 100 or more participants.

• Formulary

  • See Drug Formulary.

G                                   (index)

• Generic Drug

  • A drug that is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand drug.

• Ground Up

  • Refers to a claim from the first dollar payable by the claimant as opposed to the first dollar payable by the self-funded plan or payable by the Stop Loss plan or payable by the reinsurer of the Stop Loss plan.

H                                   (index)

• Health Benefit Plan

  • A health insurance product that is defined by a benefit contract and represents a set of covered medical related services and provider options.

• Health Maintenance Organization (HMO)

  • A type of health care plan under which the enrollees receive all the medical services they need through a specific group of participating doctors and hospitals.

• Hearing Services

  • Procedures involved in the care of or determination of problems with the ear.

• HIAA

  • Health Insurance Association of America ...the national association of health insurance companies.

• HMO

  • Health Maintenance Organization ... an organization that provides comprehensive and preventative health care services for a fixed periodic payment from the covered person (or the covered person's employer) generally through owned (or contracted) facilities and a salaried medical staff.

• Home (page)

  • Introductory navigation site page.

• Home Health Care

  • Health services rendered in the home to an individual who is confined to the home. Such services are provided to aged, disabled, sick or convalescent individuals who do not need institutional care, but who do need nursing services or therapy, medical supplies and special outpatient services.

• Home Infusion Therapy

  • The administration of intravenous drug therapy in the home. Home infusion therapy includes the following services:  solutions and pharmaceutical additives; pharmacy compounding and dispensing services; durable medical equipment; ancillary medical supplies; and nursing services.

• Hospice

  • A facility or service that provides care for a terminally ill patient and who provides support to the family. The care, primarily for pain control and symptom relief, can be provided in the home or in an inpatient setting.

• Hospital

  • An institution whose primary function is to provide inpatient services, diagnostic and therapeutic, for a variety of medical conditions, both surgical and non-surgical. In addition, most hospitals provide some outpatient services, particularly emergency care.

I

• I.D. Card/Identification Card

  • A card issued to a subscriber and possibly his/her dependents, which allows the subscriber to identify himself or his covered dependents to a provider for health care services. The card is subsequently used by the provider to determine benefit levels and to prepare the billing statement.

• IBNR

  • (Incurred But Not Reported) A reserve for claims that have been incurred but have not yet been submitted for payment. This is the reserve intended to cover claim run-out upon termination of the health benefit programs.

• Immunizations

  • An injection or oral agent given to protect an individual from a disease or infection.

• Incurred and Paid

  • An Expense both incurred during the contract period and paid during the same contract period.

• Incurred Claims

  • Refers to the accrual method of accounting for all known and unknown claims. Includes paid claims plus adjustments for claims reported but not yet paid and those incurred but not reported.

• Incurred Date

  • The incurred date is the date the covered service is rendered, the covered purchase is made, or the covered person earns periodic payment due to total disability. 

• Indemnity

  • A traditional health insurance plan that reimburses for medical services provided to patients based on bills submitted after the services are rendered. Also known as fee-for-service plans. These plans generally do not have a specific provider network.

• Individual Deductible

  • Same as Specific Deductible.

• Individual Stop Loss

  • Same as Specific Stop Loss.

• Infertility

  • Term used to describe the inability to conceive or an inability to carry a pregnancy to a live birth after a year or more of regular sexual relations without the use of contraception. Also includes the presence of a condition recognized by a physician as the cause of infertility.

• Infusion Therapy

  • Treatment accomplished by placing therapeutic agents into the vein, including intravenous feeding. Such therapy also includes enteral nutrition, (the delivery of nutrients into the gastrointestinal tract by tube).

• In-Network

  • Refers to the use of providers who participate in a health plan's provider network. Many benefit plans encourage enrollees to use participating (in-network) providers to reduce the enrollees out-of-pocket expense.

• Inpatient

  • Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.

• Investigational Procedures

  • A procedure that has revealed insufficient evidence to determine appropriateness.

J    K

L                                              (index)

• Lag

  • The usual delay between the actual time a service is rendered or a supply is supplied and the time it is paid and recorded. Lag includes both claims that have not yet been submitted and claims that have been submitted but not yet paid. Lag is the result of administrative efficiency of the provider, the employer (if employer involvement is required in supplying claim forms or verifying eligibility), the employee, and the claim administrator; human procrastination is a major factor.

• Lifetime Maximum

  • Maximum payable under the employer's plan per person.

  • Maximum payable under the Specific Stop Loss contract per person. 

• Limited Extension of Coverage

  • A Stop Loss optional benefit which provides a 90 day extension upon termination of the Specific Stop Loss.

• Loss Fund

  • A term for the funds set aside for the payment of claims based upon the covered persons and the Aggregate factors.

• Loss Fund Factor

  • Same as Aggregate Factor

M                                              (index)

• Managed Care

  • Health plan management process that utilizes selective provider contracting for patients, utilization reviews, and oversight of claims.

• Manual Cost

  • A rate or factor based on actuarial estimates rather than on the group's experience.

• Margin

  • The difference between expected paid claims and the Aggregate deductible.  Granting that the expected claims will most likely be paid in any circumstance, the margin is the corridor of risk the employer is accepting in his self-funded program. It is expressed as a percent of expected paid claims and is customarily 25%.

• Maternity Care

  • Medical care given to a woman prior to and during childbirth.

• Medical Equipment (DME)

  • Items used for patient care or support for patients with illness, malformation or injury.

• Medically Necessary

  • Healthcare services or supplies which are determined to be; Appropriate for the symptoms, diagnosis or treatment of the injury or disease;  Provided for the diagnosis or direct care and treatment of the injury or disease; Within standards of good medical practice within the organized medical community;  Not primarily for the convenience of the Eligible Person or of any Participating Provider providing covered services to the Eligible Person; and  An appropriate supply or level of service needed to provide safe and adequate care.

• Member

  • An individual or dependent who is enrolled in and covered by a managed health care plan. Also called Enrollee or Beneficiary.

• Mental Health/Behavioral Health

  • Conditions that affect thinking and the ability to figure things out and that affect perception, mood and behavior. Such disorders are recognized primarily by symptoms or signs that appear as distortions of normal thinking, or distortions of the way things are perceived (seeing or hearing things that are not there.) Disorders can also be recognized by moodiness, sudden or extreme changes in mood, depression, highly agitated or unusual behavior.

• Minimum Attachment Point

  • The lowest AAD to be used for a contract period generally stated as a dollar amount or as a percent (usually 85% to 95%) of the first month's calculated Aggregate deductive times the number of months in the contract period.

N                                                 (index)

• Network

  • The doctors, clinics, hospitals and other medical providers with which a health plan contracts to provide health care to its members. Members are generally limited to network providers for full coverage of their health costs.

• Network Provider

  • A provider or group of providers who have entered into an agreement with AssureCare to provide Covered Services.

• Non-Participating Provider

  • A medical provider who has not contracted with a health plan as a participating provider.

• Not Hospital Confined

  • A contract provision that provides that the coverage will only be available to persons (usually applies only to dependents) who are not hospital confined on the effective date of the coverage. Persons that are hospital confined become eligible upon their discharge. The matching provision for the employee is usually an actively-at-work provision.

O                                                (index)

• Occupational Therapy

  • Treatment to restore a physically disabled person's ability to perform activities such as walking, eating, drinking, dressing, toileting, and bathing.

• Out of Network

  • The use of health care providers who have not contracted with the health plan to provide services. HMO members are generally not covered for out-of-network services except in emergency situations. Members enrolled in preferred provider organizations (PPO) and point-of-service (POS) coverage can go out of network, but will pay some additional costs.

• Out-of-Pocket Maximum

  • Refers to the maximum amount that an enrollee will have to pay for expenses covered under the health plan. The maximum is a sum of all paid deductible and co-payment or coinsurance amounts.

• Outpatient

  • A patient who is receiving care at a hospital, physician office or other health facility without being admitted to the facility for an overnight stay. The term "ambulatory" is often used to describe outpatient care.

• Outpatient Surgery

  • Surgical procedures performed that do not require an overnight stay in the hospital or ambulatory surgery facility. Such surgery can be performed in the hospital, a surgery center, or physician office.

P                                                (index)

• Paid Claims

  • The total of claims actually paid during a specific time period. A straight cash accounting basis with no adjustment for anticipated or known liabilities which have not yet been paid.

• Partial Day Treatment

  • A program offered by appropriately licensed psychiatric facilities that includes either a day or evening treatment program for mental health or substance abuse. Such care is an alternative to inpatient treatment.

• Participating Agreement

  • The application completed by the participating employer when requesting membership in the Stop Loss trust.

• Participating Employer

  • A company and its subsidiaries electing to take part in a trust sponsoring a Stop Loss policy.

• Participating Provider

  • A physician, hospital, pharmacy, laboratory, or other appropriately licensed facility or provider of health care services or supplies, that has entered into an agreement with a managed care entity to provide services or supplies to a patient enrolled in a health benefit plan.

• Patients

  • An individual or dependant who is enrolled in and covered by a managed health care plan. Also called Enrollee or Beneficiary.

• PCP

  • See Primary Care Physician.

• Physical Therapy

  • Treatment involving physical movement to relieve pain, restore function and prevent disability following disease, injury, or loss of limb.

• PL

  • (Public Law)

• Plan Benefit Maximum

  • See lifetime maximum

• Plan Document

  • The master description of benefits under which the employer's health and welfare plan are administered. This is the document that tells the TPA how to pay the eligible expenses and tells the Stop Loss insurer how to validate Stop Loss claims.

• Point of Service (POS)

  • A benefit plan that allows enrollees to go outside the health plans provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do.

• Policy

  • The contract of coverage issued to the employer for non-trust coverage or to the trustees of a stop loss trust.

• PPO

  • (Preferred Provider Organization)  A type of health benefit plan designed to give enrollees incentives to use health care providers designated as "preferred providers", but that also give substantial coverage for services received from other health care providers. PPO plans can also be distinguished from HMO plans by the ability of PPO members to see any specialty physician without referral from a PCP. 

• Pre Authorization

  • The process whereby all patients insured with contracted payers are required to notify AssureCare within designated time frames of a hospital admission or a surgical procedure performed in an outpatient or freestanding surgical suite setting. Some payers may invoke penalties if the insured fails to notify AssureCare within the time frames outlined in the policy.

• Pre-Certification

  •  See Pre Authorization.

• Pre-Existing Condition

  • A health condition (other than a pregnancy) or medical problem that was diagnosed or treated before enrollment in a new health plan or insurance policy. Some pre-existing conditions may be excluded from coverage.

• Preferred Provider Organization (PPO)

  • A type of health benefit plan designed to give enrollees incentives to use health care providers designated as "preferred providers", but that also give substantial coverage for services received from other health care providers. PPO plans can also be distinguished from HMO plans by the ability of PPO members to see any specialty physician without referral from a PCP.

• Prescription

  • A written order or refill notice issued by a licensed medical profession for drugs which are only available through a pharmacy.

• Preventive Care

  • Services rendered to prevent disease.

• Primary Care Physician (PCP)

  • A doctor selected by the enrollee to be the first physician contacted for any medical problem. The doctor acts as the patient's regular physician and coordinates any other care the patient needs, such as a visit to a specialist or hospitalization.

• Prior Authorization

  • The process of obtaining advanced approval of coverage for a health care service or medication. Also called Pre-Authorization.

• PRO

  • (Peer Review Organization) A watchdog group formed by members of the same profession to guard against improper treatment or charges. Sometimes used to review questionable claims.

• Prosthetic Devices

  • A device that replaces all or a portion of a part of the human body. These devices are necessary because a part of the body is permanently damaged, is absent or is malfunctioning.

• Provider

  • A licensed health care facility, program, agency, physician or health professional that delivers health care services.

• Provider Network

  • The set of providers contracted with a health plan to provide services to the enrollees. In the case of a "fee-for-service" or non-network health plan, the provider network generally consists of all licensed providers of covered services.

Q

R                                               (index)

• Radiation Therapy

  • Treatment of disease by x-ray, radium, cobalt or high energy particle sources.

• Reasonable and Customary

  • A term referring to provider charges usually defined as "a charge made by the provider of the care or supply and does not exceed the usual charge made by most providers of like service in the same area." It will usually consider the nature and severity of the condition being treated, the medical complications, or any unusual circumstances that require more time, skill or experience.

• Referral

  • A recommendation by a physician that an enrollee receive care from a specialty physician or facility.

• Repricing

  • Also called "Pre-Pricing", this is a service that entails the calculation and/or determination of allowable charges based on, but not limited to, the AssureCare fee schedules, facility contracts and physician guidelines, prior to the claim being adjudicated by the claims payer or benefit office.

• Respiratory Therapy

  • Treatment of illness or disease that is accomplished by introducing dry or moist gases into the lungs.

• Retention

  • The portion of the premium retained by an insurance company as their cost of doing business including premium taxes, commissions, profit, claims, and other administrative expenses.

S                                               (index)

• Schedule of Benefits

  • An outline of the benefits described in the plan document.

• Second Opinion

  • The voluntary option or mandatory requirement to visit another physician or surgeon regarding diagnosis, course of treatment or having specific types of elective surgery performed.

• Self-Funding

  • The method of providing employee benefits in which the group does not purchase conventional insurance but rather elects to pay for the claims directly  (generally through the services of a TPA) with Stop Loss insurance in place to cover abnormal risks.