Medical Terminology

Whether it’s partnering with a pharmacy, healthcare provider, or employer; it’s vital that everyone has a good understanding of medical terminology. This understanding allows for better communication between all parties in the healthcare field, especially when presenting or discussing innovative solutions. It’s important to stay updated on acronyms, words and/or definitions to make sure you’re always prepared to speak amongst your peers! Here are a few words below to add to your healthcare vocabulary:

ACOAccountable Care Organizations

Groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.

Benefit Program or Program

Any self-funded health benefit plan, insurance policy, contract, government program, or other plan or program under which Members are eligible for benefits.

Benefit Program Maximum

An instance in which the cumulative payment by a Payor has met or exceeded the annual or lifetime benefit maximum (e.g., dollar amount or service count) for a particular type of Covered Service rendered to a Member in accordance with the terms of the Member’s Benefit Program

Clean Claim

Unless otherwise required by law, “Clean Claim” means a completed HCFA or CMS 1500 (or successor form), as appropriate, or other standard billing format, including ANSI 837P and ANSI 837I, containing all information reasonably required by the Payor or TPA for adjudication.

Geographic Provider Access Analysis

Allows the accessibility of health care networks to be accurately measured based on the geographic coordinates of health care provider locations

Member

Any individual and/or dependent eligible to receive health services that are covered by a plan administered by Employers Health Network or an EHN Network Payor.

Network

An arrangement of Network Providers, including facilities, physicians and other health care providers, created or maintained by Employers Health Network, under which such Network Providers have agreed to accept certain Contract Rates for Covered Services provided to Members.

Per Diem

Payment methodology that makes payment for each day of care. Institutional providers such as nursing facilities may be paid using this methodology.