Glossary

The Vocabulary Behind What a Policy Actually Pays

Eighteen terms from the payer side of behavioral health, each one written for the person who has to act on it. Definitions, what they decide, and where they are usually lost.

What a Policy Pays

4 terms

The figures every forecast is built on, and the one that hides when a claim pays short.

Allowed AmountThe maximum a health plan will count toward a covered service. Member cost share is calculated from it, and the plan's payment is what remains after that cost share.Out-of-Network BenefitOONThe coverage a health plan provides for care delivered by a provider it has no contract with.UnderpaymentA claim paid below the rate that should have applied, whether a contracted rate or the plan's own out-of-network methodology.Single Case AgreementSCAA one-time contract between a health plan and an out-of-network provider covering a specific patient's episode of care, setting an agreed rate and terms in advance.

What the Member Owes

3 terms

Three thresholds that decide how a stay collects over its length, not just at admission.

DeductibleThe amount a member pays for covered services in a plan year before the health plan begins paying.CoinsuranceThe share of the allowed amount a member pays after the deductible is met, expressed as a percentage.Out-of-Pocket MaximumOOP MaxThe most a member can be required to pay in cost sharing for covered services in a plan year.

Getting Care Approved

4 terms

Where length of stay is actually decided, and against which written standard.

Prior AuthorizationPrecertA health plan's requirement that a service be approved before it is delivered.Medical NecessityA health plan's standard for whether it will cover a service. In behavioral health it is usually assessed against published criteria sets such as ASAM, LOCUS or a...Utilization ReviewURA health plan's process for assessing whether care meets its medical necessity criteria.Levels of Care in Behavioral HealthThe graduated tiers of behavioral health treatment, from medically managed withdrawal through residential, partial hospitalization, intensive outpatient and routine...

Verifying Coverage

4 terms

What a check returns, which plan it has to reach, and who gets paid.

The 270 and 271270/271The paired electronic transactions for checking insurance eligibility. The 270 is the inquiry a provider sends; the 271 is the payer's response.Alpha PrefixThe three characters at the start of a Blue Cross Blue Shield member ID.Home PlanThe Blue Cross Blue Shield plan that issued a member's policy and holds the benefit contract.Assignment of BenefitsAOBA signed authorization in which a patient directs their health plan to pay the provider directly rather than reimbursing the patient.

After the Claim

3 terms

The documents that record what happened, and what they do and do not settle.

Clean ClaimA claim submitted with all information required for a payer to process it without requesting anything further.Explanation of BenefitsEOBThe statement a health plan sends a member after processing a claim, showing what was billed, what was allowed, what the plan paid and what the member owes.Mental Health ParityMHPAEAFederal law requiring that health plans apply no more restrictive limits to mental health and substance use benefits than they apply to comparable medical and...

Definitions Are Free. The Rate Is the Part Worth Knowing.

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