Health / Health Insurance Glossary

Due Process Clause: A provider contract provision which gives providers that are terminated with cause the right to appeal the termination.

Early And Periodic Screening Diagnostic And Treatment (EPSDT) Services: Services, including screening, vision, hearing, and dental services, provided under Medicaid to children under age 21 at intervals which meet recognized standards of medical and dental pract . . . View Full Definition

Edits: Criteria that, if unmet, will cause an automated claims processing sys- tem to 'kick out' a claim for further investigation.

Effective Date: The date your insurance is to actually begin. You are not covered until the policies effective date.

Electronic Data Interchange (EDI): The application-to-application interchange of business data between organizations using a standard data format.

Electronic Medical Record (EMR): An automated, on-line medical record containing clinical and demographic information about a patient that is available to providers, ancillary service departments, pharmacies, and others inv . . . View Full Definition

Employee Assistance Programs (EAPS): Mental health counseling services that are sometimes offered by insurance companies or employers. Typically, individuals or employers do not have to directly pay for services provided throug . . . View Full Definition

Employee Benefits Consultant: A specialist in employee benefits and insurance who is hired by a group buyer to provide advice on a health plan purchase.

Employee Retirement Income Security Act (ERISA): A broad-reaching law that establishes the rights of pension plan participants, standards for the investment of pension plan assets, and requirements for the disclosure of plan provisions and funding.

Employer-Sponsored Health Insurance: Of Americans who have health coverage, nearly 60 percent secure that coverage through an employer-sponsored plan, often called group health insurance. Millions take advantage of the coverage . . . View Full Definition

Employment-Model IDS: An IDS that generally owns or is affiliated with a hospital and establishes or purchases physician practices and retains the physicians as employees.

Enterprise Scheduling Systems: Information systems that control the use of facilities and resources for such organizations as physician groups, hospitals, and staff model HMOs.

Ethics In Patient Referrals Act: A federal act and its amendments, commonly called the Stark laws, which prohibit a physician from referring patients to laboratories, radiology services, diagnostic services, physical therap . . . View Full Definition

Exchange: The act of one party giving something of value to another party and receiving something of value in return.

Exclusions: Medical services that are not covered by an individual's insurance policy.

Exclusive Provider Organization (EPO): A healthcare benefit arrangement that is similar to a preferred provider organization in administration, structure, and operation, but which does not cover out-of-network care.

Exclusive Remedy Doctrine: A rule which states that employees who are injured on the job are entitled to workers' compensation benefits, but they cannot sue their employers for additional amounts.

Executive Committee: Committee whose purpose is to provide rapid access to decision making and confidential discussions for an MCO board of directors.

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