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Aetna External Review Program

 
External Review Glossary
A
Adverse Benefit Determination   A denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a participant's or beneficiary's eligibility to participate in a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate. This also includes rescissions of coverage and declination of coverage for individual plans only.
Annual limit many health insurance plans place dollar limits upon the claims the insurer will pay over the course of a plan year. PPACA prohibits annual limits for essential benefits for plan years beginning after Sept. 23, 2010.
Appeal A verbal or written request by a member or a member's authorized representative, requesting a change in the Initial Determination decision.  This includes but is not limited to requests related to the following:
  1. Certification of health care services; (e.g., pre-certification, concurrent review, retrospective services)
  2. Claim payment
  3. Plan interpretation
  4. Benefit determinations
  5. Eligibility (including issues where termination of coverage precludes the member from having services)
B
Balance billing when you receive services from a health care provider that does not participate in your insurer's network, the health care provider is not obligated to accept the insurer's payment as payment in full and may bill you for unpaid amount. This is known as “balance billing.”
C
COBRA coverage Congress passed the Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefit provisions in 1986. COBRA provides certain former employees, retirees, spouses, former spouses and dependent children the right to temporary continuation of health coverage at group rates. The law generally covers health plans maintained by private-sector employers with 20 or more employees, employee organizations, or state or local governments. Many states have “mini-COBRA” laws that apply to the employees of employers with less than 20 employees.
Coinsurance A percentage of a health care provider's charge for which the patient is financially responsible under the terms of the policy.
 Co-payment A flat-dollar amount which a patient may pay when visiting a health care provider.
Cost-sharing Health care provider charges for which a patient is responsible under the terms of a health plan. Common forms of cost-sharing include deductibles, coinsurance and co-payments. Balance-billed charges from out-of-network physicians are not considered cost-sharing. PPACA prohibits total cost-sharing exceed $5,950 for an individual and $11,900 for a family. These amounts will be adjusted annually to reflect the growth of premiums.
D
Deductible a dollar amount that a patient may pay for health care services each year before the insurer will begin paying claims under a policy. PPACA limits annual deductibles for small group policies to $2,000 for policies that cover an individual, and $4,000 for other policies. These amounts will be adjusted annually to reflect the growth of premiums.
Disease management a broad approach to appropriate coordination of the entire disease treatment process that often involves shifting away from inpatient and acute care to areas such as preventive medicine, patient counseling and education, and outpatient care. The process is intended to reduce health care costs and improve the quality of life for individuals by preventing or minimizing the effects of a disease, usually a chronic condition.
E
ERISA The Employee Retirement Income Security Act of 1974 (ERISA) is a Federal law enacted in 1974 which related primarily to private pension and welfare plans and was enacted to protect the interests of workers under those plans. ERISA imposes strict requirements with respect to claim procedures, standards for claim fiduciaries, documentation, reporting and disclosure requirements.
External Review Independent, third party external review of a health plans coverage denial.
F
Formulary a list of prescription drugs the health plan covers. It can include drugs that are brand name and generic. Drugs on this list may cost less than drugs not on the list. How much a plan covers may vary from drug to drug.
G
Grandfathered plan   a health plan that an individual was enrolled in prior to March 23, 2010. Grandfathered plans are exempt from most changes required by PPACA. New employees may be added to group plans that are grandfathered, and new family members may be added to all grandfathered plans.
 Group health plan an employee welfare benefit plan that is established or maintained by an employer or by an employee organization (such as a union), or both, that provides medical care for participants or their dependents directly or through insurance, reimbursement or otherwise.
H
Health Maintenance Organization (HMO) a managed care organization (health plan) that provides health care coverage through a network of hospitals, doctors and other health care providers. Typically, the HMO only pays for care that is provided from an in-network provider. Depending on the type of coverage you have, state and federal rules govern disputes between enrolled individuals and the plan.
Health Savings Account (HSA) the Medicare bill signed by President Bush on Dec. 8, 2003 created HSAs. Individuals covered by a qualified high deductible health plan (HDHP) (and have no other first dollar coverage) are able to open an HSA on a tax preferred basis to save for future qualified medical and retiree health expenses. Additional information about HSAs can be found on the U.S. Treasury Web site: http://www.treas.gov/offices/public-affairs/hsa/.
High Deductible Health Plan (HDHP) a type of health insurance plan that, compared to traditional health insurance plans, requires greater out-of-pocket spending, although premiums may be lower. In 2010, an HSA-qualifying HDHP must have a deductible of at least $1,200 for single coverage and $2,400 for family coverage. The plan must also limit the total amount of out-of-pocket cost-sharing for covered benefits each year to $5,950 for single coverage and $11,900 for families.
HIPAA (Health Insurance Portability and Accountability Act of 1996) The federal law enacted in 1996 which eased the “job lock” problem by making it easier for individuals to move from job to job without the risk of being unable to obtain health insurance or having to wait for coverage due to pre-existing medical conditions.
I
In-Network provider A health care provider (such as a hospital or doctor) that is contracted to be part of the network for a managed care organization (such as an HMO or PPO). The provider agrees to the managed care organization’s rules and fee schedules in order to be part of the network and agrees not to balance bill patients for amounts beyond the agreed upon fee.
Individual market the market for health insurance coverage offered to individuals other than in connection with a group health plan. PPACA makes numerous changes to the rules governing insurers in the individual market.
L
Lifetime limit many health insurance plans place dollar limits upon the claims that the insurer will pay over the course of an individual’s life. PPACA prohibits lifetime limits on benefits beginning with on Sept. 23, 2010.
M
Mandated benefit A requirement in state or federal law that all health insurance policies provide coverage for a specific health care service.
O
Open enrollment period a specified period during which individuals may enroll in a health insurance plan each year. In certain situations, such as if one has had a birth, death or divorce in their family, individuals may be allowed to enroll in a plan outside of the open enrollment period.
Out-of-network provider a health care provider (such as a hospital or doctor) that is not contracted to be part of a managed care organization’s network (such as an HMO or PPO). Depending on the managed care organization’s rules, an individual may not be covered at all or may be required to pay a higher portion of the total costs when he/she seeks care from an out-of-network provider.
Out-of-pocket maximum the limit on the costs a health plan member must pay for covered services. The limit can be yearly or a dollar. PPACA requires out-of-pocket limits of $5,950 per individual and $11,900 per family, beginning in 2014. These amounts will be adjusted annually to account for the growth of health insurance premiums.
P
Patient Protection and Affordable Care Act (PPACA) Legislation (Public Law 111-148) signed by President Obama on March 23, 2010. Commonly referred to as the health reform law.
Pre-existing condition exclusion The period of time that an individual receives no benefits under a health benefit plan for an illness or medical condition for which an individual received medical advice, diagnosis, care or treatment within a specified period of time prior to the date of enrollment in the health benefit plan. PPACA prohibits pre-existing condition exclusions for all plans beginning January 2014.
Preferred Provider Organization (PPO) A type of managed care organization (health plan) that provides health care coverage through a network of providers. Typically the PPO requires the policyholder to pay higher costs when they seek care from an out-of-network provider. Depending on the type of coverage you have, state and federal rules govern disputes between enrolled individuals and the plan.
Protected Health Information (PHI) Information created or reviewed by Aetna that relates to the past, present or future physical or mental condition of a member; or to the provision of or payment for his/her health care.  PHI is information that either identifies, or there is reason to believe that it could be used to identity a member.
Premium the periodic payment required to keep a policy in force.
Preventive benefits Covered services that are intended to prevent disease or to identify disease while it is more easily treatable. PPACA requires insurers to provide coverage for preventive benefits without deductibles, co-payments or coinsurance.
Q
Qualified health plan A health insurance policy that is sold through an Exchange. PPACA requires Exchanges to certify that qualified health plans meet minimum standards contained in the law.
S
Self-insured Group health plans may be self-insured or fully insured. A plan is self-insured (or self-funded), when the employer assumes the financial risk for providing health care benefits to its employees. A plan is fully insured when all benefits are guaranteed under a contract of insurance that transfers that risk to an insurer.
U
Usual, Customary and Reasonable charge (UCR)   the cost associated with a health care service that is consistent with the going rate for identical or similar services within a particular geographic area. Reimbursement for out-of-network providers is often set at a percentage of the usual, customary and reasonable charge, which may differ from what the provider actually charges for a service.


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