Glossary of Insurance Terms

Ascend to Wholeness (ATW): The activity-based, lifestyle healthcare plan with a new wellness program component. The plan offers two options: Accelerate and Access. It focuses on whole-person health and invests in you through valuable new services. Ascend to Wholeness Healthcare Plans provide comprehensive care coordination, biometric screenings, wellness assessment, free personalized health coaching, a Wellness portal and many educational resources.

Biometric screenings: Tests which measure total cholesterol and HDL cholesterol, glucose, blood pressure, height and weight, and BMI (body mass index). Optional screenings are available for LDL cholesterol and triglycerides (requiring an 8 to 12-hour fast) and body composition/percent body fat. The free confidential screening and wellness assessment are part of the Ascend To Wholeness Healthcare Plans commitment to supporting employees and their families in achieving optimal physical, mental and spiritual health.

Care coordination: Your new healthcare plans include care coordination, integrated wellness and confidential health coaching for all plan members. Accelerate Plan members who are at risk for serious health issues will be provided free care coordination, education and support through one-on-one health coaching. They will learn how to reduce risk, identify resources, overcome barriers and set goals to make lifestyle changes to improve overall health. For high-risk members, this may include telephone interactions spanning two-three months. Many of these enhanced benefits also are available to those enrolled in the Access Plan.

Claim: A payment request to the health plan for covered services provided to enrolled members. A claim can be submitted by the patient, the patient’s representative or by the healthcare professional who provided the service. File your health care claims here.

Contribution: The monthly amount you pay for healthcare coverage.

Covered Service: A service or supply that is covered by the Plan.

Co-pay: The pre-determined amount you pay for covered services each time you visit a provider or facility. Your co-pay applies to your deductible and accrues to your out-of-pocket maximum.

Co-insurance: The percentage you pay for care after meeting your deductible.

Deductible: The specified amount of money you must pay for covered services before the plan will pay a claim.

Emergency Room: The Emergency Room (ER) should be utilized for life-threatening emergencies or acute complications that need advanced imaging. It's the best place to go when you are exhibiting signs or symptoms of a heart attack, stroke, or traumatic injury. 

Other situations may include the risk of a loss of limb, broken bones, major head injuries, seizures, severe abdominal pain, severe asthma attack, uncontrollable bleeding or car accident. The ER will be able to provide the advanced care you need. The downside of going to the ER is that when ER’s are flooded with non-emergent issues, wait times are often longer. Therefore, it’s crucial that you know where to go before you go.

Explanation of Benefits (EOB): When a healthcare provider sends out bills for services rendered to a Third Party Administrator (TPA), the patient receives what is commonly called an Explanation of Benefits (EOB). An EOB resembles a bill. It contains the date of service, the code used to bill a particular service to an insurance company, the fee charged by the healthcare provider, the allowed amount under the third-party payers’ contractual fee schedule, the patient’s responsibility under the terms of their coverage, the payment made by the payer, and the contractual write-off. An entry usually the titled, “what you owe” or “your responsibility” is why some health plan members confuse an EOB with a medical bill.

Health coaching: A free telephone-based, lifestyle improvement program available to all plan members. Your personal health coach partners with you to help you with healthy lifestyle changes. Your coach doesn’t tell you what to do but helps you explore ways to address your health concerns.

HealthSCOPE: Claims administration and health management firm for claims submitted in 2018 and prior. Effective January 1, 2019, WebTPA will provide claims processing for all member health services including medical, dental, and vision. 

HIPAA: This acronym stands for the Health Insurance Portability and Accountability Act. As the health plan administrator, ARM and its partners adhere to all HIPAA privacy regulations. No personally-identifiable information will be shared with your employer (including Human Resources, your manager or supervisor). Employers only receive aggregated data stripped of personally-identifiable information.

Open enrollment: Once each year, a period of time is designated by your employer when you can sign up for health insurance or are allowed to make changes to your coverage. (An exception to this is if you experience “a qualifying event” such as marriage, divorce, a birth, etc.) Your employer should provide you with written materials that explain your benefits so that you can select the plan that is the best fit for you and your family.

Out-of-network Services: Services from a provider not included in the plan’s preferred provider organization (PPO). Non-emergency, out-of-network services are not covered by the plan. It is your responsibility to confirm if a doctor/provider or facility is part of the plan’s PPO.

Out-of-network Service Request: A form submitted by the member for prior authorization if the member needs a service or physician not part of the PPO.

Out-of-pocket maximum (OOP): The absolute maximum you’ll pay annually for healthcare services. Once you meet the OOP maximum, the health plan will pay in full for all covered services with in-network providers and facilities.

Preferred provider organization (PPO): A network of doctors, hospitals, clinics, specialists, labs and pharmacies. Members choose the providers they want to visit from among those who participate in the health insurance plan’s network called “preferred providers.”

Pre-certification: A health plan requirement in which you, as a member must contact Ascend to Wholeness Healthcare Plans in advance to receive approval for certain medical procedures and medications in order to be considered a medical necessity and therefore a covered expense. Your plan documents outline the services that require pre-certification. 

Primary Care:  Let’s start with your primary care physician (PCP). The benefit of visiting your primary doctor is the physician will know your medical history, and because of this will understand what new medications will work best with your current medications, and many times are best able to accommodate you when you are sick. They will pick up on slight variations in your health before another provider because they already established a baseline from your annual checkups. Primary care appointments are also the most cost-effective. It is ideal to establish a relationship with a primary care physician, so they can get to know you and create your medical record. Not only does a primary care provider care for acute and chronic illnesses such as diabetes, but they also provide health education, routine checkups, and overall health management.

Prior authorization: A health plan requirement in which members must obtain authorization in advance from Ascend to wholeness Healthcare Plans to receive services from an out-of-network healthcare provider for non-emergency/non-urgent care. Provided through the Out-of-network Service Request (see #16).

Telehealth: Telehealth is a benefit that will allow Plan members to have 24/7 access to a medical provider. This service is not designed in any way to take the place of a primary care physician. Think of it as a supplement to medical situations you might go to an urgent care center for, but now members can first talk or video conference with a doctor from the comfort of their home. ARM is working on the final details of this service, and more information will be sent out as it becomes available. Experience in the industry indicates that telehealth excels in the area of behavioral health services. We are excited that this confidential resource will enhance our plan members benefits in this area of healthcare.

Urgent care: A category of walk-in clinic focused on the delivery of ambulatory care in a dedicated medical facility outside of a traditional emergency room (ER). Urgent care centers primarily treat injuries or illnesses requiring immediate care, but not serious enough to require an ER visit. Because some urgent care centers are affiliated with a hospital ER, copays may vary based on how the provider bills the encounter. However, treatment at an urgent care center billed as an ER would typically cost less than an actual ER visit. As much as possible, please check for providers who participate in the AETNA Signature Administrators® Preferred Provider Organization.

Wellness assessment: A simple, secure online personal health questionnaire used to identify risk factors for conditions such as diabetes, heart disease and hypertension, often preventable with lifestyle changes. It takes about 15 minutes to complete. You will receive an actionable wellness plan based on your responses.

WebTPA: Effective January 1, 2019, WebTPA will provide claims processing for all member health services, including medical, dental, and vision. In the WebTPA member services portal, you can:

• Check your claim status
• Review your benefits
• Order an ID card
• View your electronic ID card