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Quality Insurance
Hatcher & Associates is dedicated to a no-nonsense approach to health insurance. We focus on giving you the insurance you need in a timely and cooperative manner.
Insurance for which the application has been signed, the medical examination completed, and the settlement for the premium tendered. (LI,H)***
Paid Claims.
Amounts paid to providers based on the health plan. (H)
Paid Claims Loss Ratio
Paid claims divided by total premiums. (H)
Partial Disability
A condition in which, as a result of injury or sickness, the insured cannot perform all of the duties of his occupation but can perform some. Exact definitions vary from policy to policy. (H)
Partial Disability
See Permanent Partial Disability and Temporary Partial Disability. (G,WC,H)***
Partial Hospitalization Services
Additional services provided to mental health or substance abuse patients which provides outpatient treatment as an alternative or follow-up to inpatient treatment. (H)
Participant
An employee or former employee who is eligible to receive benefits from an employee benefit plan or whose beneficiaries may be eligible to receive benefits from the plan. (LI,H,PE)***
Participating Provider
A health care provider approved by Medicare to participate in the program and receive benefit payments directly from carriers or fiscal intermediaries. (H)
Participation
The number of employees enrolled compared to the total number eligible for coverage. Many times, a minimum participation percentage is required. (H)
Peer Review
Review of health care provided by a medical staff with training equal to the staff which provided the treatment. (H)
Peer Review Organization (PRO)
Groups of physicians who are paid by the federal government to conduct pre-admission, continued stay and services reviews provided to Medicare patients by Medicare approved hospitals. (H)
Percentage Participation
A provision in a Health Insurance contract which states that the insurer will share losses in an agreed proportion with the insured. An example would be an 80-20 participation where the insurer pays 80% and the insured pays the 20% of losses covered under the contract. Often erroneously referred to as coinsurance. (H)
Permanent and Total Disability
Total disability from which the insured does not recover. When used as a definition in a policy (usually a life insurance policy rider), "permanent" is presumed after a stated period of time, commonly six months. (H)
Permanent Partial Disability
A condition where the injured party's earning capacity is impaired for life, but he is able to work at reduced efficiency. (WC,H)***
Permanent Total Disability
A condition where the injured party is not able to work at any gainful employment for the remaining lifetime. (WC,H)
Pharmacy and Therapeutics (P&T) Committee
A panel of physicians _ usually from different specialties _ who advise the health plan regarding the proper use of prescription drugs. (H)
Physical Therapist
A trained medical person who provides rehabilitative services and therapy to help restore bodily functions such as walking, speech, the use of limbs, etc. (H)
Physician Contingency Reserve (PCR)
A portion of the claim which is deducted and withheld by the health plan before payment is made to the physician. It serves as an incentive for proper quality and utilization of health care. A portion of this reserve may be returned to the physician or to pay claims where the plan needs additional funds. It is also sometimes called "withhold." (H)
Physician's Current Procedural Terminology (CPT)
This terminology includes medical services and procedures performed by physicians and other providers of health care. The health care industry uses it as a standard for describing services and procedures. (H)
Place of Service
This designates where the actual health services are being performed, whether it be home, hospital, office, clinic, etc. (H)
Point-of-Service Plan.
This plan allows a choice of whether to receive services from a participating or nonparticipating provider. (H)
Pool (Risk Pool)
A separate account which includes entries for income and expenses. It is used when a number of groups are put together for the purposes of combining their premium and paying their losses. (H)
Practical Nurse
A licensed individual who provides custodial type care such as help in walking, bathing, feeding, etc. Practical nurses do not administer medication or perform other medically related services. (H)
Pre-Admission Authorization
A cost containment feature of many group medical policies whereby the insured must contact the insurer prior to a hospitalization and receive authorization for the admission. (H)
Pre-Admission Certification
Before being admitted as an inpatient in a hospital, certain criteria are used to determine whether the inpatient care is necessary. (H)
Preexisting Condition
A physical condition that existed prior to the effective date of a policy. In many Health policies these are not covered until after a stated period of time has elapsed. (H)
Preferred Provider Organization (PPO)
An organization of hospitals and physicans who provide, for a set fee, services to insurance company clients. These providers are listed as preferred and the insured may select from any number of hospitals and physicians without being limited as with an HMO. Coverage is 100%, with a minimal copayment for each office visit or hospital stay. Contrast with Health Maintenance Organization. (LI,H)***
Prescription Medication
A drug which can be dispensed only by prescription and which has been approved by the Food and Drug Administration. (H)
Presumptive Disability
A disability involving loss of sight, hearing, speech, or any two limbs, which is presumed to be a permanent and total disability. In such cases, the insurer does not require the insured to submit to periodic medical examinations to prove continuing disability. (H)
Preventive Care
This type of care is best exemplified by routine physical examinations and immunizations. The emphasis is on preventing illnesses before they occur. (H)
Primary Care
Basic health care provided by doctors who are in the practice of family care, pediatrics, and internal medicine. (H)
Primary Care Network (PCN)
This is a group of primary care physicians who provide care to those members of a particular health plan. (H)
Primary Care Physician
Some health insurance plans require members to select and seek treatment from a primary physican who either renders treatment or refers the member to an appropriate specialist within the approved health care network. (H)
Primary Coverage
This is the coverage which pays expenses first, without consideration whether or not there is any other coverage. See also Coordination of Benefits. (H)
Prior Authorization
A cost containment measure which provides full payment of health benefits only when the hospitalization or medical treatment has been approved in advance. (H)
Probationary Period
A period of time between the effective date of a Health Insurance policy, and the date coverage begins for all or certain physical conditions. (H)
Professional Review Organization
An organization of physicians which reviews services to determine if they are medically necessary. (H)
Proration of Benefits
The adjustment of Health Insurance policy benefits by reason of the existence of other insurance covering the same contingency. (H)
Prospective Payment System
A system of Medicare reimbursement for Part A benefits which bases most hospital payments on the patient's diagnosis at the time of hospital admission. (H)
Prospective Reserve
A Life or Health Insurance reserve which it is estimated will be sufficient to pay future claims when probable future premiums, interest, and survivorship benefits are added to it. (LI,H)***
Prospective Reimbursement
A system where hospitals or other health care providers are paid annually according to rate of payment which have been established ahead of time. (H)
Provider
Any individual or group of individuals that provide a health care service such as physicians, hospitals, etc. (H)
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