Health Insurance Glossary - P Terms

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

P

Participating Provider

A health care professional, hospital, or facility that has an agreement with an insurer to discount or limit the price of certain medical services. See also In-Network Provider.

Plan Administrator

The person or company responsible for managing the day-to-day activities of a health plan, including providing plan information to potential applicants, enrolling individuals, billing and collecting premiums, and keeping records up-to-date.

Policy

A written contract of insurance, including all associated riders, endorsements and other attached documents.

Point-of-Service (POS) Plan

A health insurance plan that allows an individual to choose between in-network and out-of-network providers each time medical treatment is needed.

A Point-of-Service plan combines some of the benefits of a Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) (see below). Similar to an HMO plan, a POS plan requires members choose a Primary Care Physician (PCP) (see below) and usually provides coverage for preventive care. Similar to a PPO plan, coverage is provided for services rendered by both in-network and out-of-network providers, although services provided by an out-of-network provider may be subject to a deductible (or higher deductible), and lower level of coverage.

Preadmission Review and Certification

A review of an individual's health care status or condition, which may include Preadmission Tests, prior to the individual being approved for admission to a hospital or other in-patient health care facility. The purpose of a pre-admission review is to ensure an individual receives appropriate health care services, avoid unnecessary tests and services being provided, and prevent unnecessary costs being incurred.

Preadmission Tests

Medical tests performed prior to an individual being admitted to a hospital or other in-patient health care facility.

Preexisting Condition

A medical condition (either physical or mental) that exists prior to the effective date of a health insurance policy.

Insurance companies generally seek to exclude preexisting conditions from coverage, or increase premiums to cover the anticipated medical costs of such conditions.

For insurance purposes, pregnancy cannot be considered a preexisting condition. Genetic information about the risk of an individual developing a disease or condition cannot be considered a preexisting condition unless the individual has already been diagnosed as having that disease or condition.

See also, Preexisting Condition Exclusion Period below.

Preexisting Condition Exclusion Period

A period of time during which a health plan will not covered health care costs care related to a Preexisting Condition.

Preferred Provider Organization (PPO)

An organization of hospitals, clinics and health care professionals contracted to provide health care services at pre-arranged or discounted rates.

A Preferred Provider Organization (PPO) plan is a health plan that offers incentives, such as lower deductibles, lower co-payments, or greater coverage, for using a provider in the PPO network. An out-of-network provider may still be used, but services rendered by an out-of-network provider are typically covered at a lower rate than an in-network provider.

Unlike an HMO or POS plan (see below), members of a PPO plan are not normally required to select a Primary Care Physician (PCP) (see below).

Premium

The price of the insurance policy.

Prevailing Rate

See Reasonable and Customary.

Preventive Care

Health care intended to prevent injury or illness, or more serious injury or illness. Examples of preventive care include immunizations, routine check-ups, and physical examinations.

Primary Care Physician (PCP)

A physician that is responsible for providing and coordinating medical care and treatment, including referrals to specialists, if necessary. A primary care physician is normally a family doctor, general practitioner, or pediatrician, although some HMOs allow women to use a gynecologist as their primary care physician.

Provider

A hospital, clinic, doctor, specialist, or other health professional that provides health care services.

Provisions

Statements in an insurance policy that specify the benefits, terms and limitations of the policy.

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September 7, 2010

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