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11.1.3 Glossary

11.1.3.1 Benefits are the services payable under a specific payor plan. They are also referred to as an insurance product, such as professional services, prescription drugs, etc.

11.1.3.2 Clinical information refers to the data contained in the patient record. The data may include such things as problem lists, lab results, current medications, family history, etc. For the purposes of this chapter, clinical information is limited to diagnoses (DG1& DRG), results reported (OBX/OBR), and allergies (AL1).

11.1.3.3 Dependent refers to a person who is affiliated with a subscriber, such as spouse or child.

11.1.3.4 Eligibility/coverage refers to the period of time a subscriber or dependent is entitled to benefits.

11.1.3.5 Encounter refers to a meeting between a covered person and a healthcare provider whose services are provided.

11.1.3.6 Guarantor refers to a person who has financial responsibility for the payment of a patient account.

11.1.3.7 Healthcare provider refers to a person licensed, certified or otherwise authorized or permitted by law to administer health care in the ordinary course of business or practice of a profession, including a healthcare facility.

11.1.3.8 Payor indicates a third party entity who pays for or underwrites coverage for healthcare expenses. A payor may be an insurance company, a health maintenance organization (HMO), a preferred provider organization (PPO), a government agency or an agency such as a third party administrator (TPA).

11.1.3.9 Pre-authorization refers to the process of obtaining prior approval as to the appropriateness of a service. Pre-authorization does not guarantee coverage.

11.1.3.10 Primary care provider indicates the provider responsible for delivering care as well as authorizing and channeling care to specialists and other providers in a gatekeeper system. The provider is also referred to as a case manager or a gatekeeper.

11.1.3.11 Referral means a provider’s recommendation that a covered person receive care from a different provider.

11.1.3.12 Referring provider indicates the provider who requests services from a specialist or another primary care provider. A referring provider may, in fact, be a specialist who is referring a patient to another specialist.

11.1.3.13 Referred-to-provider typically indicates a specialty care provider who provides services at the request of a primary care provider or another specialty care provider .

11.1.3.14 Specialist means a provider of services which are beyond the capabilities or resources of the primary care provider. A specialist is also known as a specialty care provider who provides services at the request of a primary care provider or another specialty care provider.

11.1.3.15 Subscriber refers to a person who elects benefits and is affiliated with an employer or insurer.

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