Glossary

Allowance - The amount HMSA pays to the subscriber or provider for a particular healthcare service.

Benefit - A service that is covered under an HMSA plan and which meets HMSA's payment determination criteria.

Benefit Year (QUEST) - The benefit year for QUEST plans is July 1 through June 30.

Benefits Exhausted Letter - A letter from a third-party carrier stating that benefits have been exhausted.

Blue Cross and Blue Shield Association - An association of independent organizations providing insurance for hospital, medical and other services. HMSA is an independent affiliate of this association.

BlueCard Program - A program of the national Blue Cross and Blue Shield Association through which Blue Cross and Blue Shield Plans, nationwide, process medical claims for one another based on reciprocity.

Calendar Year - The period beginning January 1 and ending December 31 of a given year.

Charge - The dollar amount charged by the provider for services rendered.

Child - A subscriber's natural child, legally adopted child, stepchild, a child for whom the subscriber or his or her spouse is the court-appointed guardian, a minor child who has been adopted or placed with the subscriber for adoption.

Claim - A complete billing, or an adjustment to such billing, for covered services submitted by a participating provider on the CMS 1500 claim form, or by electronic transmission accepted by HMSA.

CMS 1500 - Nationally accepted claim form for non-institutional billing, excluding dental and pharmacy claims.

Copayment - A specified dollar among or percentage of the charge or eligible charge paid by the member for a service. Copayments are specified in the member's plan certificate.

Coverage Code - A unique code that signifies the particular benefits of a specific healthcare plan. The coverage code can be found on the HMSA member ID card.

Covered Service - A medical service or supply that qualifies for payment under the terms of the member's plan document and meets HMSA's payment determination criteria, or a preventive service that is specifically described as covered in the member's plan document.

CPT - Physician's Current Procedural Terminology, a coding structure for medical procedures issued by the American Medical Association.

Deductible - A set dollar amount of healthcare expenses for which the member is responsible before benefits become payable under his or her plan.

Dependent - The subscriber's spouse and each eligible child(ren) covered under the subscriber's healthcare plan.

Diagnosis Code - The code used to identify the diagnosis of a patient's condition. See "DSM-IV" and "ICD-9-CM/ICD-10-CM" elsewhere in this glossary.

DSM IV - Diagnostic and Statistical Manual of Mental Disorders, Revised Fourth Edition; a classification system and coding structure for psychiatric and psychological diagnoses.

Note: HMSA claims processing requires use of ICD-9-CM/ICD-10-CM diagnosis codes. DSM IV codes, while similar, are not exactly the same as ICD-9-CM/ICD-10-CM codes.

Dual Coverage - When a member has medical coverage through both HMSA and another health insurance carrier.

Dual Membership - When a member has two (or more) HMSA medical plans.

Effective Date - The date on which a person is accepted as a member by HMSA and from which eligibility for benefits begins.

Eligible Charge - is the lower of either the actual charge or the charge or the amount we establish as the maximum allowable charge. For a covered service that does not have a charge listed on the schedule, The eligible charge does not include general excise tax or any other tax.

HMSA reserves the right to adjust the charges listed in its Schedule of Maximum Allowable Charges upon 60 days written notice to participating physicians. Factors considered by HMSA in making these adjustments may include, but are not limited to, changes in the Honolulu Consumer Price Indices (all items and medical care); cost of providing medical care; the relative complexity of the service; payments for the service under federal, state and other private insurance programs; and the competitive environment.

Eligibility - A term used to describe whether a person is currently covered by an HMSA plan and eligible to receive benefits for services.

EMC - The abbreviation for electronic media claims.

Extended Therapy - When therapy (for most therapeutic categories) extends beyond 28 days (beginning on day 29), it is referred to as extended therapy. For enteral therapy, extended therapy begins on day 8.

HCPCS - The HCPCS - Level II Code Book is a reference book containing codes for durable medical equipment, medical supplies, injectable drugs, vision appliances and other miscellaneous items. The code book also contains temporary procedure codes for Medicare and Blue Cross and Blue Shield Claims.

HMO Programs - Health plans that focus on preventive care under the supervision of a specific physician or health center. Health Plan Hawaii and HMSA's HMO plans provide coverage for home IV therapy and injectables when these services are recommended by the patient's personal care physician (PCP) or health center. The PCP or health center must contact HMSA with a referral for these services. If a referral is not made, benefits will not be paid.

HMSA Akamai Advantage® - HMSA Akamai Advantage is a comprehensive plan that provides Original Medicare benefits, value-added benefits and services, and prescription drug coverage. HMSA contracts with the federal government to offer HMSA Akamai Advantage.

Homebound - When due to an illness of injury, a patient is unable to leave home, or when doing so requires a considerable and taxing effort.

ICD-9-CM - International Classification of Diseases, Ninth Revision, Clinical Modification, a classification system and coding structure of diseases.

ICD-10-CM – International Classification of Diseases, Tenth Revision, Clinical Modification, a classification system and coding structure of diseases.

Injury/Illness Report Form - A form that must be completed and signed by an HMSA member when he or she has experienced an injury or illness for which benefits may be recovered from another party.

Inquiry - request by the provider for HMSA to respond to a particular concern or question, or to resolve a specific problem involving claims filing, benefits or payments.

Length of Stay - The number of days for which inpatient services are provided, including the day of admission and excluding the day of discharge.

Maximum Allowable Charges (MAC) - The MAC is the maximum amount of compensation that a participating provider agrees to accept for a particular service through the combined payments from HMSA, the member and other payers, including payments from other insurance plans, liability payments or worker's compensation.

Medicare - A federally funded program that primarily provides medical coverage for persons who are 65 years of age and older, disabled, or have end-stage renal disease (ESRD).

Member - A person who meets applicable eligibility requirements and is enrolled in an HMSA plan.

Nursing Care Visit During Extended Therapy - Extended therapy for most therapies begins on day 29. As an exception for enteral therapy, extended therapy begins on day 8. Nursing care visits rendered to patients who are in extended therapy must be precertified.

Participating Provider - A provider who has entered into a contract with HMSA to provide healthcare services to members.

Payment Determination Criteria - Criteria used by HMSA in determining whether payment can be made. Under these criteria, a medical service rendered to an eligible member that follows standard medical practice and is deemed essential and appropriate for the diagnosis or treatment of a particular illness or injury is payable. Specific criteria exist for certain procedures, services and drugs.

PCP - Personal care physician or primary care physician.

Per Diem - An all inclusive charge that includes all services and supplies necessary to perform a given service.

PPP - Preferred Provider Plan.

Precertification - Advance authorization by HMSA that a specific service will be covered for an eligible member.

Pre-existing Condition - An illness or injury that existed on or before the start of coverage, regardless of whether its symptoms were known to the member.

Provider Adjustment - The difference between the participating provider's charge and HMSA's eligible charge. Participating providers, as agreed in their contracts with HMSA, must adjust or deduct this difference from their charge.

Rider - An extension of a basic healthcare plan that adds more or different benefits (e.g., drug, vision or dental).

Report To Provider (RTP) - Providers receive a report to provider usually on a weekly basis advising them of the results of claims processing.

Serious Mental Illness - As defined by Hawaii law such as schizophrenia, schizo-affective disorder, bipolar types I and II, and services for delusional disorder, dissociative disorder, major depressive disorder, and obsessive-compulsive disorder. These conditions are covered on par with the member's medical benefits and are not subject to the Behavioral Health benefits limits.

Service Date - The date on which a particular healthcare service was rendered by a provider to a member.

Standard Medical Practice - To be covered, all services must follow standard medical practice. This means that most physicians in the nation regard the services as safe and effective. If a service is in its trial stages (e.g., "experimental" because it is used in research on animals or "investigative" because it is or has been performed on a limited number of people), the service is not considered standard medical practice for purposes of benefit payment.

Subscriber - The person who subscribes to the particular healthcare plan and who is accepted in writing by HMSA as a member of the plan.

Waiting Period - Time period during which no benefits will be paid for a particular service, injury or illness.

Revision History