Health Insurance Glossary
Health / Health Insurance Glossary
Primary Source Verification: A process through which an organization validates credentialing information from the organization that originally conferred or issued the credentialing element to the practitioner.
Prior Authorization: In the context of a pharmacy benefit management (PBM) plan, a program that requires physicians to obtain certification of medical necessity prior to drug dispensing. Also known as a medical- . . . View Full Definition
Private Health Insurance: Private health insurance – insurance plans marketed by the private health insurance industry – currently dominates the U.S. health care landscape, with approximately two-thirds of the non-el . . . View Full Definition
Process Measures: Healthcare quality indicators related to the methods and procedures that a managed care organization and its providers use to furnish care.
Promise Keeping-Truthtelling: An ethical principle which, when applied to managed care, states that managed care organizations and their providers have a duty to present information honestly and are obligated to honor co . . . View Full Definition
Prospective Authorization: Authorization to deliver healthcare service that is issued before any service is rendered. Also known as precertification.
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 pr . . . View Full Definition
Provider Manual: A document that contains information concerning a provider's rights and responsibilities as part of a network.
Provider-Sponsored Organization (PSO): A healthcare organization—established and organized, or operated, by a healthcare provider or a group of affiliated healthcare providers to arrange for the delivery, financing, and administr . . . View Full Definition
Purchasing Alliances: Locally based, privately operated organizations that offer affordable group health coverage to businesses with fewer than 100 employees. Also known as purchasing pools, health insurance purc . . . View Full Definition
QM Committee: MCO committee responsible for oversight of the quality management program—including the setting of standards, review of data, feedback to providers, follow-up, and approval of sanctions—and . . . View Full Definition
Quality: In a managed care context, an MCO's success in providing healthcare and other services in such a way that plan members' needs and expectations are met.
Quality Management (QM): An organization-wide process of measur-ing and improving the quality of the healthcare provided by an MCO.
Quality Program: An organization-wide initiative to measure and improve the service and care provided by an MCO.
Rate Spread: The difference between the highest and lowest rates that a health plan charges small groups. The NAIC Small Group Model Act limits a plan's allowable rate spread to 2 to 1.
Rating: The process of calculating the appropriate premium to charge purchasers, given the degree of risk represented by the individual or group, the expected costs to deliver medical services, and . . . View Full Definition
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 spec . . . View Full Definition
Rebate: A reduction in the price of a particular pharmaceutical obtained by a PBM from the pharmaceutical manufacturer.
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Profit And Loss Statement: A detailed statement of income and expenses of a business that reveals the operating position of the business over a period of time. Commonly referred to a P&L.
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