Glossary

ancillary services: Medical services rendered by a hospital or other inpatient health program in support of a disease treatment plan. These may include X-ray, drug, laboratory, or other services.¹
appeal(s): A special kind of complaint made if a request for coverage of healthcare services is denied by the patient's health plan. Appeals may also address matters other than coverage.¹
benefits: The proceeds that are realized from a benefit plan. In a health plan, benefits may refer to the healthcare services you receive or the funding that is provided for these services.¹
Centers for Medicare and Medicaid Services (CMS): The federal agency that operates or oversees the Medicare, Medicaid and State Children's Health Insurance Program (SCHIP). CMS sets standards and processes to help ensure that beneficiaries in these programs receive high-quality healthcare serivces.¹
epidermal growth factor receptor (EGFR): A protein found on the surface of cells to which epidermal growth factor (EGF) binds. EGFR is found at abnormally high levels on the surface of many types of cancer cells, which may divide excessively in the presence of EGF.²
explanation of benefits (EOB): A summary statement that explains the claim and the amount that is the responsibility of the member, or the reason for non-payment.³ In the Medicare program, these are called EOB, or Explanation of Medical Benefits.
formulary: A list of specific drugs and their proper dosages, usually reviewed and approved for use by health plan members. Coverage for “nonformulary” drugs may be denied or limited. In some Medicare health plans, beneficiaries only receive coverage for formulary drugs.¹
healthcare claim: A request for payment of healthcare services received by the plan member. Claims are also called bills for all Part A and Part B services administered by Medicare Administrative Contractors, or MACs. “Claim” is the word used for Part B physician/supplier services billed to MACs.¹
health maintenance organization (HMO): An HMO provides care through a defined network of physicians, hospitals, and other healthcare providers. Individuals enrolled in an HMO generally cannot receive covered services outside the provider network. They typically select a primary care physician, who makes referrals to specialists when necessary. The HMO usually does not pay for visits to specialists without a referral, or for nonemergency care received from providers that are not designated by the HMO.
infusion: Introduction of a solution directly into the bloodstream for therapeutic purposes.
K-ras: A gene that codes for a protein involved in the EGFR pathway.
Medicaid: A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most healthcare costs are covered if you qualify for both Medicare and Medicaid.¹
Medicare: The federal health insurance program for people 65 years of age or older, certain younger people with disabilities, and people with end-stage renal disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD) and kidney transplant.¹
Medicare Part A (Hospital Insurance): Coverage for Medicare beneficiaries that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home healthcare.¹
Medicare Part B (Medical Insurance): Coverage for Medicare beneficiaries that helps pay for doctors’ services, outpatient hospital care, durable medical equipment, and some medical services that are not covered by Part A.¹
Medicare Part C: Coverage for Medicare beneficiaries that replaces Part A and Part B coverage, and may replace Part D coverage.
Medicare Part D (Medicare Drug Benefit): Coverage for Medicare beneficiaries that pays for prescription drugs not covered by Part B; coverage is offered exclusively through private plans that contract with Medicare.¹
Medicare Savings Programs: Medicaid programs that help pay some or all Medicare premiums and deductibles.¹
Medicare Summary Notice (MSN): A quarterly summary of all Medicare claims paid on behalf of the beneficiary and amount that the beneficiary is responsible for paying.
predetermination: The procedure by which some services and/or equipment may be approved prior to being performed or ordered. This is a service offered so the patients are aware of their financial responsibility prior to services being rendered or ordered.⁴
preferred provider organization (PPO): A managed care plan in which you use doctors, hospitals, and other providers that belong to the network. You can usually use doctors, hospitals, and other providers outside of the network for an additional cost.¹
prior authorization: The process of obtaining authorization for services by reviewing related documentation, verifying benefits and medical necessity, and ensuring the appropriate provider will be delivering the services.⁵
private fee for service: A type of MediShip-to-Patient Option Plan in which you may go to any Medicare-approved doctor or hospital that accepts the plan’s payment. The insurance plan, rather than the Medicare program, decides how much it will pay and what you pay for the services you get. You may pay more or less for Medicare-covered benefits. You may have extra benefits the original Medicare plan doesn't cover.⁶
supplemental health insurance (Medicare): The Medicare program that pays for a portion of the costs of physicians’ services, outpatient hospital services, and other related medical and health services for voluntarily insured aged and disabled individuals. Also known as Part B.¹
usual, customary, and reasonable charge (UCR): Charges for service that may be based on rates usually charged by physicians and providers in your area. Charge rates are compiled by independent rating services, or by the insurer that is paying a claim.⁷

References:

U.S. Department of Health & Human Services. Centers for Medicare & Medicaid services. Accessed at: http://www.cms.hhs.gov/apps/glossary/default.asp. Accessed March 17, 2010.
MedicineNet.com. MedTerms medical dictionary. Accessed at: http://www.medterms.com/script/main/art.asp?articlekey=32387. Accessed March 17, 2010.
Capital BlueCross. Glossary of terms. Accessed at: https://www.capbluecross.com/FAQs/GlossaryOfTerms/E.htm. Accessed March 17, 2010.
BlueCross BlueShield of Kansas. Glossary of health insurance terms. Accessed at: http://www.bcbsks.com/CustomerService/Providers/faqs/glossary/P.htm. Accessed March 17, 2010.
Physicians Plus Insurance Corporation. Prior authorization of procedures. Accessed at: http://www.pplusic.com/uploads/media/F_PriorAuth.pdf. Accessed March 17, 2010.
Medicare/U.S. Department of Health & Human Services. Glossary. Accessed at: http://www.medicare.gov/Glossary/search.asp?SelectAlphabet=P&Language=English#Content. Accessed March 17, 2010.
Texas Department of Insurance. Glossary of common insurance terms. Accessed at: http://www.tdi.state.tx.us/consumer/glossary.html. Accessed March 17, 2010.