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Insurance Definitions

Patient Protection and Affordable Care Act (ObamaCare)

In 2014, the Affordable Care Act (ACA) was implemented. The purpose was to provide more affordable health insurance to groups of Americans who previously did not have access. The expansion of Medicaid eligibility and the creation of individual insurance exchanges by each state served to increase coverage for 20 - 24 million additional people. The individual exchanges (each state had the option to create their own or join the federal exchange) provided subsidies based on income so that people who were not covered by an employer (e.g. self-employed people, young people not covered by their parents, or people working in jobs that did not offer insurance) could afford to have health insurance. The efficacy and structure of the ACA remains a hot political topic and the bill may be amended at some point, but for now it exists mostly in its original format.

Insurance Programs

Federal Programs (Nationally Funded)

  • Department of Defense (DOD). The DOD is responsible for 2 health insurance programs: Veteran's Affairs and TriCare (insurance for active duty personnel and their families who do not have direct access to a military base with a hospital.)
  • Medicare
    • The Centers for Medicare and Medicaid Services (CMS) is responsible for administering Medicare. Each state may have a different administrator for their Medicare Services, but everything is regulated by CMS. To see which company is the administrator of each state, click Medicare Administrator Information and select the A/B Jurisdiction Map.
    • Something that can be confusing is that patients who have Medicare may not have it through the Medicare Administrator. They may have enrolled with a commercial plan (e.g. Kaiser or Aetna) to replace their Medicare plan. Most enrollees meet either age requirements (e.g. 65 +) or are disabled and applied for Medicare early to cover their disability.

State-Funded Programs

  • Medicaid. Each State is responsible for their own Medicaid program. Patients who have Medicaid may also have replacement policies instead of using the state administrator. They may have enrolled with a commercial plan (e.g. Kaiser or Aetna) to replace their Medicaid plan. Normally, Medicaid enrollees must meet income requirements to be covered under Medicaid.
  • State Children's Health Insurance Program (SCHIP). Many states have a separate fund to cover Children where Medicaid may not.

Commercial (Private Payer)

Any health plan (e.g. Aetna, Cigna, Humana, United who is not funded by a Federal or State program. People covered by these plans are normally covered as a part of their employment or have purchased individual plans.

It may be confusing when a Commercial payer is also an administrator for one of the Federal or State programs, but it is important to understand which entity (Federal, State, or Commercial) is initially funding the plan because there may be different rules around pre-certification, covered benefits, and payment.

Benefit Plan Concepts

  • Member. Any person covered under a health insurance plan; a subscriber or eligible dependent.
  • Subscriber. The person who carries the insurance; usually the employed person.

Provider Concepts

  • NPI (National Provider Identifier). A number issued to a person or a non-person entity (e.g. practice, hospital, etc.) by the National Plan & Provider Enumeration System (NPPES).
  • Credentialing. A process of establishing the qualifications of licensed professionals, organizational members or organizations, and assessing their background and legitimacy; this process is separate from the contracting process. In order to be paid by the health plan at an In-Network rate, the provider must be both credentialed and contracted with the health plan.
  • Contracting. Health Plans contract with Providers to provide services to Health Plan Members at a discounted rate. In order to be paid by the health plan at an In-Network rate, the provider must be both credentialed and contracted with the health plan.

Optum Concepts (Claims Clearinghouse integrated with patientNOW)

Note: If Optum paperwork is not completed, you may experience a delay in claims payment.

  • Optum Enrollment. Paperwork that each client must complete in order to send claims electronically from patientNOW through Optum.
  • EMC Agreements. Many health plans accept the Optum Enrollment as the only required paperwork to send an electronic claim. However, there are plans (e.g. Medicare and BC/BS) that might require additional paperwork to submit claims through Optum. During the enrollment process, these agreements should be completed and submitted to Optum.
  • ENS Message Center. The older of Optum's websites that allow you to review claims submitted for rejection and acceptance.
  • Optum Intelligent EDI. The new Optum website for reviewing and tracking submitted claims. As of November 1, 2017, none of patientNOW's clients have been migrated to the new system. This migration will occur over the next year.
  • ERA (Electronic Remittance Advice). This service offered by Optum allows for the insurance plans to deposit funds directly to your account and then provide an electronic explanation of benefits (ERA). You must enroll in this service separately. Check with Optum for more information.