Glossary

P

Paid Claim

The term "paid claim" 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
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
POP

The term "POP" means premium only plan.

Related Terms: Premium-Only Plan
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
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: Health Maintenance Organization, 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
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 Account, 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.

Primary Plan

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.

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