E
E
Effective Date: The date when a contract or policy becomes active.
Electronic Data Interchange (EDI): Refers to the computer-automated exchange of information between two agencies or organizations. This is also referred to as electronic commerce.
Eligibility Date: The date listed in a policy or contract when a person becomes eligible for insurance benefits.
Effectiveness / Efficacy of Treatment: Refers to the probability level that medical treatment will benefit a patient.
Eligible Employee / Person: Refers to an individual who meets coverage requirements. Qualifications for coverage might include working at least 35 hours per week or 40 hours per two-week periods.
Eligible Expenses: Expenses for medical services or supplies that are covered by the insurance plan.
Emergency: Refers to a serious medical condition that results from sickness, mental illness, or injury and requires immediate medical attention to avoid further health issues or loss of life.
Emergency Center: Scroll to Free-Standing Emergency Medical Service Center.
Employee: A person who is employed within a specific group. This individual is sometimes referred to as an enrollee or subscriber.
Employee Assistance Program (EAP): Refers to services that assist employees, their families, and employers in locating solutions for either workplace problems or problems that exist within the employee's personal life. These services may include elder care, childcare, marital concerns, etc... EAPs may provide either voluntary or mandatory access to mental health benefits that are available via an integrated behavioral health program.
Employee Contribution: the amount an employee pays to their health insurance premium.
Employee Retirement Income Security Act of 1974, Public Law 93-406 (ERISA): A federal law that stipulates reporting, grievance disclosure, and appeal requirements of group life and health plans. It is a law that is associated with the private--not public--sector.
Employer Contribution: Refers to the amount an employer pays toward an employee's health insurance premium. This amount varies among employers. Employer contributions may be based on percentages, dollar amounts, length of service, employee family status, and so forth.
Encounter: Refers to a physical meeting between an insured member and a healthcare provider for medical services.
Encounters Per Member Per Year: Refers to the number of member encounters on an annual basis.
Enrollee: An individual who is enrolled in a health insurance plan and is eligible for benefits associated with their plan.
Enrolling Group / Unit: Refers to an employer or some other entity that contracts with an insurer for healthcare benefits.
Enrollment: Refers to an insurance plan's total number of subscribers or enrollees.
Episode of Care: Pertains to the medical treatment extended to an individual for disease management.
Evidence of Coverage: See Certificate of Coverage.
Evidence of Insurability (EOI): Refers to an individual's health status after completion of a thorough medical examination. This proof is used to assess whether a person may be excluded from coverage due to pre-existing medical conditions. Insurers also use this examination to determine eligibility and rates regarding life insurance.
Exclusions: Conditions or circumstances that are ineligible for health insurance coverage or reimbursement.
Exclusive Provider Organization (EPO): Refers to coverage associated with services exclusively from network providers.
Expected Claims: Refers to the projected claims level associated with a covered individual or group for a prescribed contract period.
Experience: The history of claims that are paid during a contract period.
Experience Rating: Method used for setting rates that are based in whole or part on previous claims for a specific group.
Experimental, Investigational, or Unproven Procedures: Refers to medical supplies, medical treatments and procedures, drug therapies, and devices that have been deemed ineffective to treat a condition or illness for that they were designed for and do not have scientific evidence to support their efficacy or safety.
Explanation of Benefits (EOB): Lists the insured individual's covered rendered services and the amount billed or the amount paid.
Extended Care Facility: A licensed nursing home or skilled nursing center that provides 24-hour nursing care and operates in accordance with local and state laws. Typically, these facilities provide custodial care, intermediate care, or a combination of both.
Extension of Benefits: A policy provision that allows medical coverage beyond the policy's termination date for covered individuals who are not actively working or have dependents who are hospitalized on the termination date.