Glossary

Glossary

P

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

Related Terms: Claim, Expected Paid Claims
Paid Contract
A paid contract is a type of excess-loss policy that covers claims paid within the policy year, regardless of the date of service.

Related Terms: Incurred and Paid Contract, Run-in Contract, Stop-Loss Coverage
PCP
The term "PCP" means primary care physician.

Related Terms: Primary Care Physician
PDA
The term "PDA" means the Pregnancy Discrimination Act.

Related Terms: Pregnancy Discrimination Act
PHI
The term "PHI" means protected health information.

Related Terms: Protected Health Information
Plan Administrator
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.

Related Terms: Plan Sponsor
Plan Document
A plan document is a comprehensive and detailed description of the benefits and provisions under which a plan is administered.

Related Terms: Amendment, Employee Benefits Plan, Employee Welfare Benefits Plan, Summary of Material Modifications, Summary Plan Description
Plan Sponsor
A plan sponsor is the entity that establishes and maintains a benefits plan.

Related Terms: Plan Administrator
Plan Year
A plan year is the 12-consecutive-month period that a plan identifies for keeping records and filing a Form 5500 for tax purposes.

Related Terms: Benefit Year, Form 5500
Point of Service — POS
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.

Related Terms: Enhanced Provider Option, Health Maintenance Organization, Preferred Provider Option, Referral
POP
The term "POP" means premium only plan.

Related Terms: Premium Only Plan
POS
The term "POS" means point of service.

Related Terms: Point of Service
PPO
The term "PPO" means preferred provider option.

Related Terms: Preferred Provider Option
Preemption of State Law
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.

Related Terms: Employee Retirement Income Security Act of 1974, Internal Revenue Code, Mandated Benefits
Pre-Existing Condition
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.

Related Terms: Enrollment Date, Health Insurance Portability and Accountability Act of 1996, Newborns' and Mothers' Health Protection Act, Omnibus Budget Reconciliation Act, Small Employer Group Health Coverage Act, Waiting Period
Preferred Provider Option — PPO
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.

Related Terms: Enhanced Provider Option, Health Maintenance Organization, Point of Service, Primary Care Physician, Referral
Pregnancy Discrimination Act — PDA
The PDA forbids employers from discriminating against employees on the basis of pregnancy, childbirth, or other related medical conditions.

Related Terms: Family and Medical Leave Act of 1993, Newborns' and Mothers' Health Protection Act, Pre-Existing Condition
Premium Only Plan — POP
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.

Related Terms: Cafeteria Plan, Flexible Benefits Plan, Flexible Spending Arrangement, Qualified Benefits
Primary Care Physician — PCP
A PCP is a designated health care professional who diagnoses, treats, and coordinates a covered person's health care needs and provides specialist referrals when necessary.

Related Terms: Enhanced Provider Option, Point of Service
Primary Plan
A primary plan is the plan of an insurance carrier that, when coordinating benefits with another plan, has the responsibility to process and pay a claim before another plan.

Related Terms: Coordination of Benefits, Secondary Plan
Protected Health Information — PHI
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

Related Terms: Business Associate, Covered Entity, Gramm-Leach-Bliley Act, Health Insurance Portability and Accountability Act of 1996, Notice of Privacy Practices
Provider
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.

Related Terms: In-Network Provider, Out-of-Network Provider
Psychiatric Care
Psychiatric care is behavioral or psychoanalytic care.

Related Terms: Behavioral Care
Psychoanalytic Care
Psychoanalytic care is behavioral or psychiatric care.

Related Terms: Behavioral Care

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