Change Healthcare Notice

Glossary Template Headline

Schedule of Allowances: List of dollar amounts payable for medical and surgical procedures performed by a provider.
Second Opinion: The option or recommendation to visit another physician or surgeon regarding diagnosis, course of treatment or having specific types of elective surgery performed.
Second Surgical Opinion (SSO): Included among the features of Medical Management programs, SSO provides coverage for a second opinion from a qualified surgical specialist to group members seeking elective surgery. Mandatory SSO requires that group members seek the second opinion.
Separate/Stacked Out-of-Pocket Maximum: For individuals: the maximum dollar amount a member will pay out-of-pocket in coinsurance, copays and/or deductibles in a calendar year for covered expenses. Once the out-of-pocket is met by the member, the plan pays 100 percent of the allowed amount for covered services for the rest of the benefit period.

For families: when one family member meets the individual out-of-pocket maximum dollar amount, his or her services will be covered at 100 percent up to the Allowed Benefit. Each family member cannot contribute more than the individual out-of-pocket maximum amount. The family out-of-pocket maximum must be met before the services for all remaining family members will be covered at 100 percent.
Self-Insurance: Practice of an individual, group of individuals, employer or organization that assumes complete responsibility for losses, which might be insured against, such as health care expenses. In effect, "self-insured" groups have no real insurance against potential losses and instead maintain a fund out of which is paid the contingent liability subject to self-insurance.
Service Area: The geographic area in which a health plan delivers health care through a contracted network of participating providers.
Service Description: A description of the services performed.
Skilled Nursing Facility (SNF): A licensed institution (or a distinct part of a hospital) that provides continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services.
Specialist: A participating physician who provides non-routine care, such as a dermatologist or orthopedist.
Speech Therapy: Treatment of the correction of a speech impairment, which resulted from birth, disease, injury or prior medical treatment.
Subscriber: The employee or member of a group who applies for coverage or applies for coverage on an individual, or has a non-employer-sponsored contract and is the person whose name is on the contract. See Policyholder.
Substance Abuse/Chemical Dependency: The use of any drug for purposes other than those for which it is normally intended or in a manner or in quantities other than directed. Chemical dependence is the compulsion to continue taking a drug to produce desired effects or to prevent the onset of ill effects that occur when it is not taken.
Summary of Benefits: An overview of how the total charges were considered in processing this claim.