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| Early And Periodic Screening, Diagnostic, And Treatment (EPSDT) Services |
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Services, including screening, vision, hearing, and dental services, provided underMedicaid to children under age 21 at intervals which meet recognized standards of medical and dental practices and at other intervals as necessary in order to determine the existence of physical or mental illnesses or conditions. Plans offeringMedicaid Coverage to EPSDT Participants must provide any service that is necessary to treat an illness or condition that is identified by screening.
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| EDI |
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See Electronic Data Interchange (EDI).
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| Edits |
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Criteria that, if unmet, will cause an automated Claims processing system to "kick out" a Claim for further investigation.
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| Effective Date |
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The date Coverage under this plan begins for a Covered Person. The Covered Person's Coverage begins at 12:01 a.m. local time at the Certificate Holder's state of residence.
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| Elective Benefits |
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Lump sum payments which the Insured may generally choose in lieu of periodic payments for certain injuries, such as fractures and dislocations.
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| Elective Indemnities |
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See Elective Benefits.
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| Electronic Data Interchange (EDI) |
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The application-to-application interchange of business data between organizations using a standard data format (EDI).
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| Electronic Medical Record (EMR) |
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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 involved in patient treatment or care.
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| Eligibility Date |
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The date that a person is eligible for Benefits.
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| Eligibility Period |
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(1) The period of time during which potential Members of a Group Life or Health program may enroll without providing Evidence of Insurability. (2) The period of time under a Major Medical Policy during which reimbursable expenses may be accrued.
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| Eligibility Requirements |
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Requirements imposed for eligibility for Coverage, usually in a Group insurance or pension plan.
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| Eligible Dependent |
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A Dependent of a Covered Person (spouse, child, or other Dependent) who meets all requirements specified in the contract to qualify for Coverage and for who Premium payment is made
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| Eligible Drugs |
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A list of Prescription Drugs that are covered by a particular Part D plan. Drugs listed on the Formulary are also called Eligible Drugs. A Formulary can also be called a preferred-drug list (PDL), or a select drug list.
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| Eligible Employee |
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An employee who is eligible based on the requirements as indicated in the Group Contract.
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| Eligible Expenses |
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Expenses as defined in the Health Plan as being eligible for Coverage. This could involve specified Health Services fees or "customary and reasonable charges."
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| Eligible Person |
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Similar to Eligible Employee except it could be a contract covering people who are not employees of a specified employer. An example might be members of an association, union, etc.
ForMedicare Plans, this typically means persons over age 65 or otherwise eligible forMedicare.
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| Elimination Period |
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A loosely used term, sometimes designating the Probationary Period, but most often designating the Waiting Period in a Health Insurance (HI) Policy. See also Probationary Period and Waiting Period.
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| Emergency |
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An Injury or disease which happens suddenly and requires treatment within 24 hours.
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| Emergency Accident Benefit |
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A Group medical Benefit which reimburses the Insured for expenses incurred for Emergency Treatment of accidents.
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| Emergency Confinement |
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An Inpatient stay for a Sickness or an Injury that develops suddenly and unexpectedly and if not treated immediately on an Inpatient basis would:
1. Endanger the Covered Person's life; or
2. Cause serious bodily impairment to the Covered Person.
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| Emergency Room |
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A place affiliated with and physically connected to an Acute Medical Facility (Hospital) and used primarily for short term Emergency Treatment.
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| Emergency Treatment |
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Treatment, services or supplies for a Sickness or an Injury that develops suddenly and unexpectedly and if not treated immediately on an Inpatient basis would:
1. Endanger the Covered Person's life; or
2. Cause serious bodily impairment to the Covered Person.
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| Emergi-Center |
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See Free-Standing Emergency Medical Service Center.
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| Employee Assistance Programs (EAPs) |
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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
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| Employee Benefit Program |
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Benefits offered an employee at his place of work by his employer, covering such contingencies as medical expenses, disability, retirement, and death, usually paid for wholly or in part by the employer. These Benefits are usually insured.
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| Employee Benefits Consultant |
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A specialist in employee Benefits and insurance who is hired by a group buyer to provide advice on a Health Plan purchase.
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| Employee Certificate of Insurance |
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The employee's evidence of Participation in a Group insurance plan, consisting of a brief summary of plan Benefits. The employee is provided with a Certificate of Insurance rather than the actual insurance Policy.
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| Employee Contribution |
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The employee's share of the Premium costs.
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| Employee Retirement Income Security Act (ERISA) |
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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.
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| Employer Contribution |
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The portion of the cost of a Health Insurance (HI) plan which is borne by the employer.
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| Employer Purchasing Coalitions |
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See Purchasing Alliances.
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| Employment-Model IDS |
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An IDS that generally owns or is affiliated with a Hospital and establishes or purchases physician practices and retains the physicians as employees.
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| EMR |
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See Electronic Medical Record (EMR).
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| Encounter |
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Each time a person meets with a Health Care Provider to receive services, is a separate "Encounter."
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| Encounters Per Member Per Year |
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The total number of Encounters per year divided by the total number of Members Per Year.
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| Enrollee |
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The person who is the primary Insured. Under an individual or family policy, this person is the applicant. Under an employer-sponsored Group health Policy, this person is the employee.
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| Enrolling Unit |
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The organization (such as an employer) that contracts for Participation in a Health Insurance (HI) plan.
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| Enrollment |
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Used to describe the total number of Enrollees in a Health Plan. It may also be used to refer to the process of enrolling people in a Health Plan.
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| Enrollment Period |
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The amount of time an employee has to sign up for a contributory Health Plan.
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| Enrollment Period - Medicare Part D |
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The period during which individuals may enroll for an insurance Policy,Medicare, HMO Benefits. For Medicare Part D, there are different "Enrollment Periods", the IEP, AEP, OEP, and SEP.
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| Enterprise Scheduling Systems |
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Information systems that control the use of facilities and resources for such organizations as physician groups, Hospitals, and Staff Model HMOs.
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| Entire Contract Clause |
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A provision in an insurance contract stating that the entire agreement between the Insured and the insurer is contained in the contract, including the application if it is attached, declarations, insuring agreements, Exclusions, conditions and endorsements.
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| Episode of Care |
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The health care services given during a certain period of time, usually during a Hospital stay
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| EPO |
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See Exclusive Provider Organization (EPO).
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| EPSDT Services |
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See Early And Periodic Screening, Diagnostic, And Treatment (EPSDT) Services.
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| ERISA |
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See Employee Retirement Income Security Act (ERISA).
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| Ethics In Patient Referrals Act |
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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 Therapy services, Home Health Services, pharmacies, Occupational Therapy services, and suppliers of Durable Medical Equipment in which the physician has a financial interest.
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| Evidence of Coverage |
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See Certificate of Coverage.
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| Evidence of Insurability |
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Proof of physical condition. This may be provided through physician records or by the results of an Examination.
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| Examination |
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The Medical Examination of an applicant for Life or Health Insurance (HI).
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| Examined Business |
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Coverage written on an applicant who has been examined and who has signed the application but has paid no Premium.
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| Examiner |
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A physician appointed by the Medical Director of a Life or Health insurer to examine applicants.
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| Excepted Period |
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See Probationary Period.
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| Exchange |
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The act of one party giving something of value to another party and receiving something of value in return.
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| Excluded Period |
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See Probationary Period.
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| Exclusion Period |
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A period of time when an insurance company can delay Coverage of a Pre-Existing Condition - Long Answer. Sometimes this is called a pre-existing condition Waiting Period.
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| Exclusions |
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Items not covered by an insurance Policy. Part D drug plans have two types of Exclusions. The first type is the drugs thatMedicare has excluded from Coverage under Part D, no Part D plan will cover these. The second type is the drugs excluded from a particular plan's list of covered drugs, or Formulary, this list varies by Part D plan.
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| Exclusions and Limitations |
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Medical services that are either not covered or limited in Benefit by a Health Insurance (HI) Policy.
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| Exclusive Provider Organization (EPO) |
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A type of Preferred Provider Organization (PPO) where individual Members use particular preferred Providers rather than having a choice of a variety of preferred Providers. EPOs are characterized by a primary physician who monitors care and makes Referrals to a Network of Providers.
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| Exclusive Remedy Doctrine |
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A rule which states that employees who are injured on the job are entitled to Workers' Compensation Indemnity Benefits, but they cannot sue their employers for additional amounts.
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| Executive Committee |
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Committee whose purpose is to provide rapid access to decision making and confidential discussions for an MCO board of directors.
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| Executive Director |
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In a Managed Care Plan, individual responsible for all operational aspects of the plan. All other officers and key managers report to this person, who in turn reports to the board of directors.
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| Expected Claims |
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The estimated Claims for a person or Group for a Contract Year based usually on actuarial statistics.
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| Expected Morbidity |
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The expected incidence of Sickness or Injury within a given Group during a given period of time as shown on a Morbidity Table.
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| Expense |
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A Policy's share of the company's operating costs, fees for Medical Examinations and inspection reports, Underwriting, printing costs, commissions, advertising, agency expenses, Premium Taxes, salaries, rent, etc. Such costs are important in determining dividends and Premium rates.
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| Experience |
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The actual cost of providing healthcare to a Group during a given period of Coverage.
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| Experience Rating |
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A Rating method under which an MCO analyzes a Group's recorded healthcare costs by type and calculates the group's Premium partly or completely according to the group's Experience.
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| Experimental or Investigational Services |
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Treatment, services, supplies or equipment which, at the time the charges are Incurred, the Insurance Carrier determines are:
1. Not proven to be of benefit for Diagnosis or treatment of a Sickness or an Injury; or
2. Not generally used or recognized by the medical community as safe, effective and appropriate for Diagnosis or treatment of a Sickness or an Injury; or
3. In the research or investigational stage, provided or performed in a special setting for research purposes or under a controlled environment or clinical protocol; or
4. Obsolete or ineffective for the treatment of a Sickness or an Injury; or
5. Medications used for non-FDA approved indications and/or dosage regimens.
For any device, drug, or biological product, final approval must have been received to market it by the Food and Drug Administration (FDA) for the particular Sickness or Injury. However, final approval by the FDA is not sufficient to prove that treatment, services or supplies are of proven benefit or appropriate or effective for Diagnosis or treatment of a Sickness or an Injury. Any approval granted as an interim step in the FDA regulatory process, such as an investigational device exemption or an investigational new drug exemption, is not sufficient.
Only the insurance carrier can make the determination as to whether charges are for Experimental or Investigational Services based on the following criteria:
1. Once final FDA approval has been granted, the usage of a device for the particular Sickness or Injury for which the device was approved will be recognized as appropriate if:
a. It is supported by conclusive evidence that exists in clinical studies that are published in generally accepted peer-reviewed medical literature or review articles; and
b. The FDA has not determined the medical device to be contraindicated for the particular Sickness or Injury for which the device has been prescribed..
2. Once final FDA approval has been granted, the usage of a drug or biological product will be recognized as appropriate for a particular Sickness or Injury if the FDA has not determined the drug or biological product to be contraindicated for the particular Sickness or Injury for which the drug or biological product has been prescribed and the prescribed usage is recognized as appropriate medical treatment by:
a. The American Medical Association Drug Evaluations; or
b. The American Hospital Formulary Service Drug Information; or
c. The United States Pharmacopeia Drug Information; or
d. Conclusive evidence in clinical studies that are published in generally accepted peer-reviewed medical literature or review articles.
3. For any other treatment, services or supplies, conclusive evidence from generally accepted peer-reviewed literature must exist that:
a. The treatment, services or supplies have a definite positive effect on health outcomes. Such evidence must include well-designed investigations that have been reproduced by non-affiliated authoritative sources, with measurable results, backed up by the positive endorsements of national medical bodies or panels regarding scientific efficacy and rationale; and
b. Over time, the treatment, services or supplies lead to improvement in health outcomes which show that the beneficial effects outweigh any harmful effects; and
c. The treatment, devices or supplies are at least as effective in improving health outcomes as established technology, or are useable in appropriate clinical contexts in which established technology is not employable.
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| Experimental or Unproven Procedures |
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Any health care services, supplies, procedures, therapies, or devices that the Health Plan determines regarding Coverage for a particular case to be either (1) not proven by scientific evidence to be effective, or (2) not accepted by health care professionals as being effective.
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| Expert System |
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Software that attempts to replicate the process an expert uses to solve a problem in order to arrive at the same decision that an expert would reach.
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| Explanation of Benefits (EOB) |
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Statement sent by Health Plans to persons who have experienced a Claim under the Health Plan. The explanation of Benefits (EOB) details the charges for the services received, the amount the Health Insurance (HI) company will pay for those services, and the amount the insured person will be responsible for paying.
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| Explanation of Medicare Benefits |
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A notice which is sent to theMedicare patient which provides information designed to explain how the Claim is to be paid.
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| Extended Care Facility |
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A facility such as a Nursing Home which is licensed to provide 24-hour nursing care service in accordance with state and local laws. Three levels of care may be provided--skilled, intermediate, custodial, or any combination.
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| Extended Coverage |
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A provision in certain Health policies, usually Group, to allow the Insured to receive Benefits for specified losses sustained after the termination of Coverage, such a maternity expense Benefits incurred for a pregnancy in progress at the time of the termination.
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| Extension of Benefits |
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A condition in the insurance Policy which allows Coverage to continue beyond the expiration date of the policy in the case of employees who are not actively at work or Dependents who are hospitalized on that date. The Extended Coverage applies only where the employee or Dependent is disabled as of that date and continues only until the employee returns to work or the Dependent leaves the Hospital.
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