Glossary

The term "paid claim" refers to the total dollar amount of all claims actually paid under a plan during a specific time period.

A paid contract is a type of excess-loss policy that covers claims paid within the policy year, regardless of the date of service.

The term "PCP" means primary care physician.

The term "PDA" means the Pregnancy Discrimination Act.

The term "PHI" means protected health information.

A plan administrator is a person or entity who is responsible for the day-to-day functions and management of a plan.  A plan administrator often employs persons or firms to process claims and perform other plan-related services.

A plan document is a comprehensive and detailed description of the benefits and provisions under which a plan is administered.

A plan sponsor is the entity that establishes and maintains a benefits plan.

A plan year is the 12-consecutive-month period that a plan identifies for keeping records and filing a Form 5500 for tax purposes.

A POS plan is a type of health plan that utilizes primary care physicians to coordinate participants' access to medical services through referrals.  A POS plan provides both in-network and out-of-network benefits, but it offers out-of-network benefits at a lower percentage of coverage than in-network benefits.

The term "POP" means premium only plan.

The term "POS" means point of service.

The term "PPO" means preferred provider option.

Portions of the Employee Retirement Income Security Act of 1974 (ERISA) supersede state laws that regulate group health plans.  ERISA preempts certain state laws because these laws deal with federal issues on which state laws often provide inconsistent guidance.

A pre-existing condition is a physical or mental condition for which medical advice, diagnosis, care, or treatment was recommended or received within a specified period ending on an individual's enrollment date in a health plan.  If the recommendation occurs within the specified period ending on the individual's enrollment date, the condition is a pre-existing condition.  However, a covered person will not be subject to any pre-existing condition limitation in connection with a pregnancy.  Further, a newborn who begins coverage at birth or a child who is adopted or being placed for adoption with a participant in accordance with OBRA 1993 or HIPAA is not subject to any pre-existing condition limitation if the newborn or the child being adopted or placed for adoption with the participant is covered under the plan within 30 days after the birth, adoption, or placement for adoption.

A PPO is a plan design that offers a network of physicians, hospitals, and other medical providers that have agreed to provide health care at discounted fees.  Participants who are covered under a PPO plan do not need referrals to receive care from in-network or out-of-network physicians, nor must participants select a primary care physician.

The PDA forbids employers from discriminating against employees on the basis of pregnancy, childbirth, or other related medical conditions.

A POP is a Section 125 flexible benefits plan that allows participants to pay the required contributions for their health coverage under an employer's group health plan and certain other insurance programs with pre-tax dollars.

A PCP is a designated health care professional who diagnoses, treats, and coordinates a covered person's health care needs.

A primary plan is a plan that, when coordinating benefits with another plan, has the responsibility to process and pay a claim before another plan.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) defines PHI as any individually identifiable health information that covered entities or their business associates create or receive.  The information identifies the covered person or there is a reasonable basis to believe the information can be used to identify the covered person (whether living or deceased).  The following components of a covered person's information will enable identification:

1. Names
2. Street address, city, county, precinct, or ZIP code
3. Dates directly related to a covered person's receipt of health care treatment, including birth date, health facility admission and discharge date, and date of death
4. Telephone numbers, fax numbers, and electronic mail addresses
5. Social security numbers
6. Medical record numbers
7. Health plan beneficiary numbers
8. Account numbers
9. Certificate/license numbers
10. Vehicle identifiers and serial numbers, including license plate numbers
11. Device identifiers and serial numbers
12. Web Universal Resource Locators (URLs)
13. Biometric identifiers, including finger and voice prints
14. Full face photographic images and any comparable images
15. Any other unique indentifying number, characteristic, or code

A provider is a health care professional or facility that provides medical care, such as a doctor, specialist, nurse, health center, physical therapist, laboratory, or hospital.

Psychiatric care is behavioral or psychoanalytic care.

Psychoanalytic care is behavioral or psychiatric care.