Notes

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Type of medical services

PREVENTIVE :
design for a prevention or deduction

-well baby
-well child
-immunization well woman and Men Adult Preventive benefits
-Routine pap smear
-routine mammogram
-routine exam
-flu shot


DIAGNOSTIC PROCEDURE
supporting evidence in a diagnosis
- X-ray
-Magnetic Resonance Angiography
-Magnetic Resonance imaging (MRI)
-computed axial tomography CAT
-bone density
-sleep study
-ultrasound
-mammography

SURGICAL PROCEDURE
removal or replacement
-biopsy
-colonoscopy
-bariatric surgery
-Transplant
-cataract surgery
-coronary artery bypass
-mastectomy

REHABILITATION THERAPIES
helping patient recuperate
-Occupational therapy
-speech therapy
-vision therapy
-physical therapy
-chiropractic therapy


inpatient care
This type of care is for a patient who requires a stay in a hospital for more than 24 hours. Progress in modern medicine and the advent of comprehensive outpatient clinics ensure that patients are only admitted to a hospital when they are extremely ill or have severe

out patient care
Outpatient care, sometimes called ambulatory care, describes medical care or treatment that does not require an overnight stay in a hospital or medical facility.
Outpatient services include:

• Wellness and prevention
• Diagnosis
• Treatment
• Rehabilitation
physical trauma.

intravenous IV
Intravenous therapy is the administration of liquid substances directly into a patient’s vein. Intravenous therapy may be used to correct electrolyte imbalances, to deliver medications, for blood transfusion or as fluid replacement to correct, for example, dehydration.

home health care

This includes health care provided in a patient’s home by licensed healthcare providers. Home care aims to enable people to remain at home rather than using residential, long-term, or institutional-based nursing care.

durable medical equipment DME

Purchased or rented items such as hospital beds, iron lungs, oxygen equipment, seat lift equipment, wheelchairs, and other medically necessary equipment prescribed by a healthcare provider to be used in a patient’s home. A medically necessary external insulin pump could be covered as durable medical equipment (DME) for those with Diabetes.

emergency medicine

Emergency medicine, also known as accident and emergency medicine, is the medical specialty concerned with treatment of unforeseen illness or injury requiring immediate medical attention. Emergency medicine is most often delivered in hospitals and examples include care of patients following car accidents or heart attack.

home infusion

The IV administration of therapeutics – analgesics, antibiotics, chemotherapy, and prenatal nutrition – outside a formal healthcare environment. Home infusion therapy benefits patients, providers, and insurers – providing patients with clinically appropriate treatment in the comfort and convenience of their own home, improving quality of life and yielding significant cost savings for all involved.

prosthetics and prostheses
In medicine, a prosthesis (plural: prostheses) is an artificial device that replaces a missing body part, which may be lost through trauma, disease, or congenital conditions. Prosthetics include artificial limbs, eyes, or heart valves.

pre authorization
confirmed medical necessity
control health care cost
reduce duplication, waste

in patient
elective services
arrange by non member facility

pre certification
notification
coverage

preauthorization
exclusion not covered
limitation visit amount

-December 8 2026-


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PATIENT PROTECTION
FLAT DOLLAR AMOUNT THAT A MEMBER PAY WHEN VISITING A CLINIC

MEDICARE
• Federal program providing healthcare coverage for eligible individuals 65 or older • Under 65 receiving Social Security Disability Insurance (SSDI) for a certain amount  of time,
• Under 65 and have End-Stage Renal Disease (ESRD), regardless of income or assets. "

Group Health Plan
• Employee welfare benefit plan
• Established or maintained by an employer or by an employee organization
• Provides medical care for participants and their dependents

Medicare Supplement (Medigap) Insurance
• Private insurance policies
• Purchased to “fill in the gaps” not covered by original Medicare

Health Insurance Portability and Accountability Act of 1996 (HIPAA) Two main purposes:
• Provide continuous health insurance coverage for workers who lose or change their job,
• Reduce the administrative burdens and cost of healthcare

Out-of-pocket Limit
• Annual limitation on all cost-sharing for which patients are responsible,
• PPACA requires out-of-pocket limits set annually per individual/family. • Amounts adjusted annually to account for growth of health insurance premiums.

Health Maintenance Organization
• Provide healthcare coverage through a network of hospitals, doctors, and other healthcare providers.

Pre-Existing Condition Exclusion
• Period of time an individual receives no benefits for a condition for which an individual received advice, diagnosis, care or treatment within a set time prior to enrollment in the plan.
• PPACA prohibited pre-existing condition exclusions in 2014.

Medicaid
• Joint state and federal program that provides healthcare coverage to eligible categories of low income individuals.
• Eligibility varies by state.

Preventive Benefits
• Covered services intended to prevent/identify a disease while easily treatable.
• PPACA requires preventive benefits without deductibles, copayments or co-insurance.