PBM Glossary Terms C
Appro-Rx helps improve the way pharmacy benefits management is done every day to help lower prescription costs. However, we understand that the world of PBMs can be confusing. Below we have answered your most frequently asked questions to give you a better understanding of your needs!
A method of paying medical providers through a pre-paid, flat monthly fee for each covered person. The payment is independent of the number of services received or the costs incurred by a provider in furnishing those services.
A process of identifying individuals at high risk for problems associated with complex health care needs and assessing opportunities to coordinate care to optimize the outcome.
Treatment of malignant disease by chemical or biological antineoplastic agents.
An alternative medicine therapy administered by a licensed Chiropractor. The Chiropractor adjusts the spine and joints to treat pain and improve general health.
A request for payment of benefits for health care services provided to a member
The Consolidated Omnibus Budget Reconciliation Act of 1985, commonly known as COBRA, requires group health plans with 20 or more employees to offer continued health coverage for you and your dependents for 18 months after you leave your job. Longer durations of continuance are available under certain circumstances. If you opt to continue coverage, you must pay the entire premium, plus a two percent administration charge.
The portion of covered expenses that a member is responsible for paying, after first meeting any applicable deductible amount
A legal agreement between an individual subscriber or an employer group ("Contract holder"), and, a health plan that describes the benefits and limitations of the coverage. Also known as a Benefit Certificate or Policy.
An option to purchase individual coverage at a negotiated rate by a person who is leaving an employee group.
Coordination of Benefits (COB)
A provision that is intended to avoid claims payment delays and duplication of benefits when a person is covered by two or more plans providing benefits or services for medical, dental or other care or treatment. It avoids claims payment delays by establishing an order in which plans pay their benefits and provides the authority for the orderly transfer of information needed to pay claims promptly. It may avoid duplication of benefits by permitting a reduction of the benefits of a plan when, by the rules established by this provision; it does not have to pay its benefits first. Plan documents include a description of the COB provision.
The specified dollar amount or percentage required to be paid by or on behalf of a Member in connection with benefits.
Covered Benefits or Covered Services
Those medically necessary services and supplies which are covered in whole or in part under the plan, subject to all the terms and conditions of the group agreement or group insurance policy.
A systematic approach to assessing a provider's qualifications and record on issues relating to professional competence and conduct. This includes a review of relevant training, academic background, experience, licensure, certification, etc.
Any type of care where the primary purpose of the type of care provided is to attend to the Member's daily living activities which do not entail or require the continuing attention of trained medical or paramedical personnel. Examples of this include, but are not limited to, assistance in walking, getting in and out of bed, bathing, dressing, feeding, using the toilet, changes of dressings of non-infected, post-operative or chronic conditions, preparation of special diets, supervision of medication which can be self-administered by the Member, general maintenance care of colostomy or ileostomy.
Customary and Reasonable
The amount customarily charged for the service by other providers in the same geographic area (often defined as a specific percentile of all charges in the community), and the reasonable cost of services for a given patient. Also called "Usual, Customary, and Reasonable"(UCR).