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LetterAcronymDefinition
Medicare (Part A)Part of the Medicare law providing benefits for hospitalization, extended care and nursing home care to Medicare beneficiaries with no premium payment.
Medicare (Part B)Part of the Medicare law providing medical-surgical benefits to Medicare beneficiaries for a modest premium.
Medigap555-555-0199@example.com
MemberAn eligible individual who is enrolled in an insurance plan. A member may be a subscriber or a dependent.
Mental Health ServicesServices primarily to treat any disorder that affects the mind or behavior.
MEOBMedicare Explanation of Benefits
MHAMaryland Hospital Association
MHINMaryland Health Information Network
MMMajor Medical
MPOSMaryland Point of Service
MSGRMaryland Small Group Reform
MSSOPMandatory Second Surgical Opinion Program
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NAICNational Association of Insurance Commissioners
NASCONational Account Service Corporation
NCQANational Committee for Quality Assurance
NDCNational Drug Code
NetworkA group of multi-specialty medical groups and individual practice doctors that are contracted to provide services to members of a health plan.
Network ProviderA medical provider who has contracted with a health plan as a participating provider.
Non-Participating ProviderA medical/ dental provider who has not contracted with a particular health plan within its participating provider network. The member is responsible for the total charge for services rendered.
NPNurse Practitioner
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OBRAOmnibus Budget Reconciliation Act of 1986
Occupational TherapyTreatment of a physically disabled person by means of constructive activities designed and adapted to promote restoration of the person's ability to perform activities of daily living and those tasks required by the person's particular occupation or role. It is not recreational or diversionary therapy.
OCLOutstanding Claims Liability
OOA/ITSOut-of-Area Program/Inter-Plan Teleprocessing Services
OOPOut-of-Pocket
OPOutpatient
OPAPOutpatient Pre-Treatment Authorization Plan
Open EnrollmentDesignated period of time during which an employee may enroll in group health coverage. Also, designated period of time during the year when individuals without group coverage may enroll in health coverage without needing medical underwriting.
OPLOther Party Liability
Out-of-Pocket Limit or Out-of-Pocket MaximumThe maximum dollar amount a member will pay out-of-pocket in coinsurance, copays and/or deductibles in a calendar year for covered indemnity expenses. Once the out-of-pocket limit is met, the plan pays 100% of the allowed amount for covered services for the rest of the benefit period.
Out of NetworkThe 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) coverages can go out-of-network, but will pay higher out-of-pocket costs.
OutpatientPatient who receives hospital care without being admitted as an inpatient.
Outpatient SurgerySurgical procedures performed that do not require an overnight stay in the hospital or ambulatory surgery facility. Such surgery can be performed in the hospital, surgery center or physician's office.
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PACPolitical Action Committee
PARParticipating (plan, hospital, physician, etc.)
Partial Day TreatmentA program offered by 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 ProviderIndividual physicians, hospitals and professional health care providers who have a contract with CareFirst BlueCross BlueShield and/ or CareFirst BlueChoice, Inc. to provide services to its members at a discounted rate and to be paid directly for covered services.
PCPA physician selected by the member, who is part of the plan network, who provides routine care and coordinates other specialized care. The PCP should be selected from the network that corresponds to the plan in which you are a member. The physician you choose as your PCP may be a family or general practitioner, internist or pediatrician.
PCP555-555-0199@example.com
PDRPhysicians Desk Reference
PHNPreferred Health Network (of Maryland) -- (Merged into BlueChoice)
Physical TherapyTreatment by a licensed therapist involving physical movement to relieve pain, restore function and prevent disability following disease, injury or loss of limb.
PIMSProvider Information Management System
PIPPersonal Injury Protection/Proposal and Installment Process
Plan Allowance (Allowed Amount or Allowable Charge)The maximum dollar amount a contract allows for services covered, regardless of the provider's actual charge. A provider who participates in the network cannot charge the member more than this amount for any covered service.
Plan Benefit Maximum555-555-0199@example.com
PolicyholderThe employee or member of a group who applies for coverage or applies for coverage on an individual, or has a non-employer-sponsored contract and is the person whose name is on the contract.
POSThese plans include in-network (HMO) and out-of-network (PPO or traditional major medical) options that enable members to select which network and level of benefits they want to utilize at the time services are required.
PPAPreferred Provider Arrangement
PPNPreferred Provider Network
PPOAn agreement between a medical provider and a health care carrier for the delivery of services to a specific member population using discounted fees for cost savings. This relates to only a fee arrangement, and does not imply that any provider is more or less qualified than another.
Pre-AuthorizationApproval necessary for designated procedures or hospital admissions. When care is received in-network, the primary care physician or specialist is usually responsible for obtaining pre-authorization. For out-of-network services, the member is responsible for obtaining pre-authorization.
Pre-Certification555-555-0199@example.com
Pre-Existing ConditionAn illness or condition that you or another member had prior to applying for health insurance. In some cases, these conditions may be subject to a waiting period for benefits or excluded from coverage.
PremiumsPeriodic amounts paid by or on behalf of members for ongoing health care coverage. It does not include any deductibles or copayments the plan may require.
PrescriptionA written order or refill notice issued by a licensed medical professional for drugs or devices (e.g., syringes, needles for diabetics) that are only available through a pharmacy.
Preventive CareCare rendered by a physician to promote health and prevent future health problems for a member who does not exhibit any symptoms. Examples are routine physical examinations and immunizations.
Prior Authorization555-555-0199@example.com
Prosthetic DevicesA device which 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.
ProviderPerson, organization or institution licensed to provide health care services.
Provider NetworkThe set of providers contracted with a health plan to provide services to the members. In the case of a fee-for-service or non-network health plan, the provider network is generally all licensed providers of covered services.
PTPhysical Therapist
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QAQuality Assurance
QIQuality Improvement
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Radiation TherapyTreatment of disease by X-ray, radium cobalt or high-energy particle sources.
ReferralA written recommendation by a physician that a member may receive care from a specialty physician or facility.
Respiratory TherapyTreatment to improve or preserve lung function.
RFPRequest for Proposal
RiderProvision added to a contract, which increases or limits benefits or coverage.
RNRegistered Nurse
RPTRegistered Physical Therapist
RXPrescription Drug
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Schedule of AllowancesList of dollar amounts payable for medical and surgical procedures performed by a provider.
Second OpinionThe option or recommendation to visit another physician or surgeon regarding diagnosis, course of treatment or having specific types of elective surgery performed.
SEGOSmall Employer Group Options
Self-InsurancePractice of an individual, group of individuals, employer or organization that assumes complete responsibility for losses, which might be insured against, such as health care expenses. In effect, "self-insured" groups have no real insurance against potential losses and instead maintain a fund out of which is paid the contingent liability subject to self-insurance.
Service AreaThe geographic area in which a health plan delivers health care through a contracted network of participating providers.
SNFA licensed institution (or a distinct part of a hospital) that provides continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services.
SpecialistA participating physician who provides non-routine care, such as a dermatologist or orthopedist.
Speech TherapyTreatment of the correction of a speech impairment, which resulted from birth, disease, injury or prior medical treatment.
SRASpecial Rating Arrangement
SROSelf Referral Option
SSASocial Security Administration
SSOIncluded among the features of Medical Management programs, SSO provides coverage for a second opinion from a qualified surgical specialist to group members seeking elective surgery. Mandatory SSO requires that group members seek the second opinion.
SubscriberThe employee or member of a group who applies for coverage or applies for coverage on an individual, or has a non-employer-sponsored contract and is the person whose name is on the contract.
Substance Abuse/Chemical DependencyThe use of any drug for purposes other than those for which it is normally intended or in a manner or in quantities other than directed. Chemical dependence is the compulsion to continue taking a drug to produce desired effects or to prevent the onset of ill effects that occur when it is not taken.
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TEFRARequires employers with 20 or more employees to offer active employees and their spouses aged 65-69 the same level of health care benefits offered to younger employees. These employees will have their regular group coverage as primary and Medicare as secondary.
Termination DateThe date indicated in an insurance contract as the date coverage expires.
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TPAThird Party Administrator
Traditional Insurance555-555-0199@example.com
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UCPUtilization Control Program
UCP+Utilization Control Program Plus
URThe evaluation of the medical necessity, efficiency and/or appropriateness of health care services and treatment plans.
Urgent CareA condition that requires prompt medical attention, but is not a threat
Utilization ManagementManaging the use of medical services to ensure that a patient receives necessary, appropriate high-quality care in a cost-effective manner.
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VSSOPVoluntary Second Surgical Opinion
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Well Baby/Well Child CareRoutine care, testing, checkups and immunizations for a generally healthy child from birth through the age of six.
Wellness ProgramA health management program which incorporates the components of disease prevention, medical self-care and health promotion.
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