Glossary

This information is provided as a general guideline only. Your company may have its own unique processes and procedures that are different than those shown below. Contact your company's Human Resources or Employee Relations department for specific instructions.

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

A

Adjustments Count
The number of adjusted claim checks.

Adjustments Total
The total dollars of adjusted claim checks.

Admits
Number of hospital inpatient admissions for provider of service.

Aggregate
A limit in an insurance policy stipulating the most it will pay for all covered losses sustained during a specified period of time, usually one year.

Aggregate Claim Amount
The estimated net aggregate claim amount. This is the difference between the aggregate liability and actual claims assumed to apply to the aggregate contract.

Aggregate Liability
The client's claim liability based on the reinsurance contract. The formula is: census for each line of coverage multiplied by the aggregate factors for each line of coverage.

Allowable
Amount allowed for processing identified claims. The formula is: disallowed dollars deducted from charges submitted.

Amount Reimbursed
The amount reimbursed by the reinsurance carrier.

Amount Open
The amount of claim that has been filed with the reinsurance carrier, but is not yet reimbursed.

Amount Unreported
The amount of claim that has exceeded the specific but has not yet been filed with the reinsurance carrier.

Archive
Archives are the original, no longer used, records which are kept because of their continuing interest and relevance. A place where reports are kept for future reference.

Archive Period
The archive period is the span of time that a report will be retained in the archive for future reference. The archive period based on the scheduled frequency of the report

Archive Report Inventory
The Archive Report Inventory is a listing of scheduled reports created after the current report cycle period.

Auto-Audit
A set of software rules that allow screening of claims by a physician.

Average Charge
Average charge per admission for provider of service. The formula is: total charges submitted divided by the number of inpatient admissions.

Average Cost Per Claim
The average dollar amount paid for administrative and/or medical services rendered for a type of service (e.g., admissions, physician services, outpatient claims). The formula is: dollar amount divided by number of services rendered.

Average Day Charge
The average charges per inpatient day. The formula is: average charge divided by the number of inpatient days.

Average Day Paid
The average paid per inpatient day. The formula is: average paid divided by the number of inpatient days.

Average Discount
The average PPO discount applied. The formula is: total PPO discount amount divided by the number of claims.

Average Paid
Average paid per admission for provider of service. The formula is: the total amount paid divided by the number of inpatient admissions.

Average Length of Stay (ALOS)
The average number of days in an inpatient facility for each admission. The formula is: number of inpatient days divided by the number of admissions.

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B

Backup Withholding (BWH)
Backup withholding taxes deducted from check.

Bank Account
Bank account number applied for processed claim(s).

Benefit
Total dollars considered prior to tax deductions for current claim.

Benefit To Date
Total dollars considered prior to tax deductions for entire disability period.

Benefit Type
Type of coverage or service applicable to processed claim.

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C

Calendar Year
The inclusive period of time from Jan. 1 of any year through Dec. 31 of the same year. This may pertain to deductible amounts, out-of-pocket provisions and maximum amounts.

Charges
Charges submitted for identified criteria (plan number/location code/group, etc.)

Check Amount
The amount of the issued check.

Check Date
The issue date of the check.

Check Group
The number that is assigned to bank account and benefit types.

Check Number
Check number issued from a health plan bank account.

Check Type
Code indicating check transaction type.

Claim
Any itemized bill submitted for payment at the request of the enrollee, physician, hospital or other provider.

Claimant
The person or entity submitting a claim.

Claims Count
The number of claim checks (medical, dental and/or vision) issued.

Claims Total
The total dollars for medical, dental and/or vision claim checks issued.

Claim Number
An eight-digit number that is assigned to each claim processed.

Contract Information
Pertinent information regarding the terms of the reinsurance coverage.

Contract Year
The 12-month period following the effective date or subsequent renewal date of a client contract.

Co-Insurance
Amount of co-insurance applied (patient out-of-pocket expense) to allowable charges.

Coordination of Benefits
The process of determining benefits used when a member has more than one health insurance carrier and Benesight is the secondary carrier.

Co-Payment
A specified flat dollar amount a member pays for a specific service, usually when seeing a PPO physician. For example, if the office visit co-payment is $10 and the office visit is $70, the member would pay $10 to the physician at the time of service and the plan would pay $60, less the PPO discount. This is only true if the plan pays 100 percent benefit. Some plans may only pay 90 percent of the charge. Also referred to as a front-end deductible.

COB Reimbursement
Amount paid out of Coordination of Benefits savings.

COB Savings
Dollar amount saved due to coordination of benefits determined by deducting primary carrier's plan payment from this plan's benefits.

Contract Period
The contract period of the current reinsurance contract.

Corporation
A corporation is an artificial being, invisible, intangible, and existing only in contemplation of law. Being the mere creature of law, it possesses only those properties, which the charter of its creation confers upon it, either expressly or as incidental to its very existence.

Coverage

Current Procedural Technology (CPT-4)/(CPT code)
Every medical procedure (e.g., surgery, office visit, lab work, etc.) has a five-digit code called a CPT code or procedure code. The first digit of a CPT code represents the type of service rendered:

• 1, 2, 3, 4 ,5, or 6: surgery
• 7: radiology
• 8: pathology
• 9: medical
• 0: anesthesia
  

Current Report Inventory
The Current Report Inventory is a listing of scheduled reports for the current report cycle.

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D

Date Paid
Date claim paid by creating a check and/or EOB.

Days Paid
Number of days paid for disability claim.

Days Paid to Date
Total number of days paid to date for a disability claim period.

Deductible
The amount of expenses the patient must incur and pay before the plan will begin to provide benefits for certain services. For example, if a benefit is subject to a $150 deductible and the expense for a medical service is $200, the patient is responsible for $150 of the charge and the plan would consider the remaining $50.

Diagnosis Code (ICD-9)
The International Classification of Diseases, Ninth revision. The universal coding method used to indicate a diagnosis or medical condition.

Diagnosis Related Grouping (DRG)
A billing method that hospitals in some states are required to use and all other hospitals may choose to use. With this method, a hospital will charge a flat rate based on diagnosis, rather than billing each separate service rendered.

Disabled Date
Beginning disability date.

Disability
Any condition resulting in limitations that interfere with a person's ability to perform his/her customary work, or that results in substantial limitations in one or more major life activity.

Disability Benefit
An amount paid, in lieu of salary, to an individual who is disabled. Individuals must qualify for such benefits per the plan's requirements.

Disability Type
Type of disability claim filed.

Disallowed
Dollars disallowed for charges submitted.

Discount
PPO Network discount applied for the identified provider of service.

Duplicate Charges
Charges that have been submitted more than once for payment and have been previously adjudicated.

Drill-down
A detail report of information derived from a summary report.

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E

Employee
A person employed by the company whose benefits we administer. For example, if John Doe works for the Nuclear Power Plant, he is their employee. Benesight refers to these employees as "members."

Employee Initial
First and middle initials of an employee or retiree.

Employee Last Name
The last name of an employee or retiree

Enrollee
The employee that elects to have coverage under the health benefit plan their company offers. For example, John Doe of the Nuclear Power Plant elects to be covered under the health benefit plan the Nuclear Power Plant offers. He is the enrollee in the health benefit plan.

Enrollee Social Security Number
The social security number of an employee or retiree.

Enrollment Medical
Medical Enrollment counts based on the reinsurance contract.

Enrollment Dental
Dental Enrollment counts based on the reinsurance contract.

Episode of Care
The health care services given during a certain period of time, usually during a hospital stay

Expected Return to Work Date
Date claimant is expected to return to work.

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F

Factors
The aggregate attachment factors for the different lines of coverage.

Flexible Spending Benefits
Flexible spending allows employees to pay for un-reimbursed healthcare expenses such as deductibles, co-insurance payments, routine vision or dependent care expenses with pre-tax dollars. Because flexible benefit plans involve pre-tax salary, Both the employee and employer realize tax savings.

Flex Year
Either a plan year or calendar year, usually a 12-month time period.

Flex Transaction Type
Type of flexible spending account (FSA) transaction (e.g. contribution, expense or payment).

Flex Expense Type
Type of flexible spending account transaction (FSA) entered into the Benesight claims system.

Flex Reference Number
Reference dates for expenses and incurred time frames.

Fund
Account number assigned to a group and bank account.

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G

Group
A client for which Benesight supplies claim processing, customer service and other benefit administration functions.

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H

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I

ICD-9
See Diagnosis Codes or International Classification of Diseases.

Incurred Date
The beginning date of a medical or dental service. For instance, if a patient entered a hospital on 2/18/98 and left the hospital on 2/20/98, 2/18/98 would be the incurred date.

International Classification of Diseases (ICD-9)
This book lists the codes assigned to each disease or diagnosis, numerically (in Volume 1 and alphabetically in Volume 2). Both medical professionals and benefit industry professionals (like Claims Analysts) use ICD codes, sometimes called diagnosis codes.

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J

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K

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L

Length of Stay (LOS)
The number of days a covered person stayed in an inpatient facility for each admission.

Location
The distinction of employees or benefits within a group. Each location could be for different physical locations, job function or simply a different benefit plan.

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M

Major Medical Benefit
When the plan pays less than 100 percent for a service and the patient is responsible for coinsurance and a deductible.

Manual Count
The number of manual checks issued.

Manual Total
The total dollar amount of the manual checks issued.

Member
Any person covered on the health benefit plan. This includes the dependents, spouse and enrollee.

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N

Net Benefit Count
The result of Net Issued Count plus the number of adjusted claims, No Pay claims and claim refunds processed.

Net Benefit Total
The result of net issued dollars less the dollars of adjusted claims and claim refunds processed plus the dollars of No Pay claims.

Net Issued Count
The result of total claim checks issued plus total manual checks issued plus any voided claim checks.

Net Issued Total
The result of total dollars for claim checks plus manual checks less any voided claim checks.

Net Paid
The result of total dollars for claim checks plus manual checks less any voided claim checks.

Net Payment
Dollar amount paid after all applicable claims calculations. Calculated by reducing allowable charges with all applicable network discounts, plan limitations and patient out-of-pocket expenses.

No Pay Count
The number of No Pay claims.

No Pay Total
The total dollars of No Pay claims.

Non Covered Charges
Charges that have been disallowed because the service is not a covered benefit in the plan.

Non-PHI
The result of total dollars for claim checks plus manual checks less any voided claim checks.

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O

On-Demand Reports
A report function that allows selection and filtering options relevant to each report.

On-Demand Report Tool
The tool used to create On-Demand Reports.

Other
Coverage for treatment obtained by a covered person temporarily outside the network services area.

Out-of-pocket maximum
Total dollar amount an insured will be required to pay for covered medical services during a specified period, such as one year. The out-of-pocket maximum may also be called the stop-loss limit or catastrophic expense limit.

Over Specific
The amount that exceeds the specific contract deductible.

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P

Parameters
Selection criteria used for building On-Demand Reports.

Payee
The name of the provider or enrollee that a check is issued to.

Payment Period
Date range for disability claim payment.

Percentage of Specific
The percentage of the specific deductible that has been reached.

Plan
Defines a set of benefits given to each member covered under the group.

Plan Limitations
Plan limitations are similar to day maximums except that they do not limit the number of services or visits for which the plan will provide benefits. Plan limitations limit the circumstances under which the plan will provide benefits. For example, a plan may choose to cover cosmetic surgery only after a disfiguring accident.

Plan Year
The 12-month fiscal period in which financial records are kept. The plan year may be, but is not required to be, the same 12-month period as the benefit year.

Preferred Provider Organization (PPO)
A network of physicians and facilities with which an organization has contracted to offer medical care at reduced rates.

Preferred Provider Organization (PPO) Discount
PPO network discount applied to allowable charges.

Procedure Code
Also referred to as CPT code. Indicates what procedure was performed.

Provider Identification Number
A number that identifies a provider in the claims system. This number can be a Social Security number or a Tax ID number assigned by the Federal Government. The Federal Government uses this number for tax purposes. See also Tax Identification Number.

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Q

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R

Reasonable and Customary Charge
A charge for health care, which is consistent with the going rate or charge in a certain geographical area, for identical or similar services.

Reasonable and Customary Fees (also known as Usual and Customary)
The average fee charged by a particular type of health care practitioner within a geographic area. The term is often used by medical plans as the amount of money they will approve for a specific test or procedure. If the fees are higher than the approved amount, the individual receiving the service is responsible for paying the difference. Sometimes, however, if an individual questions his or her physician about the fee, the provider will reduce the charge to the amount that the insurance company has defined as reasonable and customary.

Received Date
The date a claim is received by Benesight.

Refunds Count
The number of claim refunds processed.

Refunds Total
The total dollars of claim refunds processed.

Register Type
Code indicating register type or check register category.

Register Date
Run date of register to update contributions, expenses, and payments.

Reimbursement
Payment of expenses actually incurred as a loss covered by the policy.

Report Type
A description of a report that is available to users. A Non-PHI Summary.

Reporting Period
A reporting period is a span of time in which the data is collected.

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S

Scheduled Reports
Reports that are generated at a certain date and time with a specified report period.

Sort
The arrangement/order of report data.

Specific Reimbursement
The amount that exceeds the Specific level that is assumed reimbursable under the Specific portion of the reinsurance contract.

Stop-loss Provisions
A limit in a health insurance policy that provides for 100% payment of expenses after total patient out-of-pocket expenses exceed a certain contractual dollar amount.

Summary
A summary of the contract to date accumulation of claims compared to the aggregate liability, for the same period, with an estimated claim amount.

Suffix
Numeric value that identifies a specific provider and or address assigned within our provider database.

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T

Threshold
The minimum or maximum range of data contained in a report.

Tax Identification Number (TIN)
The nine-digit number assigned to a corporation or partnership by the IRS for income reporting purposes. The digit format is 00-0000000. Much like a Social Security number, it is used to report business income.

Total Discount
Dollars applied as PPO discount for each category.

Turnaround Time (TAT)
The measure of a process cycle from the date a transaction is received to the date completed. For claims processing, it's the number of calendar days from the date a claim is received until the date processing is finished or the claim is paid. Also known as TAT.

Type of Service
A code located on the HCFA form that indicates the type of service performed.

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U

Usual and Customary Reduction
Charges that have been disallowed because the fees exceeded usual and customary guidelines.

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V

Voids Count
The number of voided medical, dental, and or vision claim checks.

Voids Total
The total dollars of voided medical, dental and or vision claim checks.

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W

X

Y

Z

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