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Paid Claims: Refers to amounts paid in accordance with contract obligations of the insurance plan's sponsor or the insurance carrier. The amounts do not include ineligible charges.
Paid Claims Loss Ratio: Refers to paid claims that are divided by health premiums.
Participating Provider: Refers to a healthcare provider that is contracted with a health insurance plan in order to deliver healthcare services to a plan member. This provider maybe a doctor, hospital, healthcare facility, or pharmacy. Also known as an in-network provider.
Participation: Refers to the employees and their dependents who are enrolled in a health plan.
Payer: Entity that pays for healthcare insurance coverage.
Percent of Charge: Refers to a reimbursement method that employs a percent discount from the insurer's charged bill in order to calculate the proper amount to pay the healthcare provider.
Peer Review: Refers to the quality evaluation of provided healthcare by qualified medical staff.
Peer Review Organization (PRO): Refers to the entity that reviews the quality of care and admissions, readmissions, and discharges for both Medicaid and Medicare. It is also referred to as the professional standards review.
Per Diem: Refers to the all-included per-day rate for a bed or specific type of service. Per diem rates are often negotiated with hospitals for services for inpatients.
Per Member Per Month (PM/PM): Refers to a formula that describes the relationship to the amount of per-month members for a specified time period. This formula is as follows: unit/member months. Also, see member months.
Pharmacy and Therapeutics (P& T) Committee: Refers to a panel of physicians and pharmacists who advise on the safe and effective usage of prescriptions medications. One of the essential functions of the committee is to manage a drug formulary.
Physician: A medical doctor or doctor of osteopathy. To be deemed as such, a physician must be credentialed and licensed to practice.
Physician Contingency Reserve (PCR): See Withhold
Physician-Hospital Organization (PHO): Scroll to provider sponsored organization
Physician Performance Incentive Program: Refers to a program designed to reward doctors with financial compensation. Performance measures can include access, utilization, quality, and service.
Physician's Current Procedural Terminology (CPT): Refers to a list of medical services and procedures offered by healthcare providers. Each service is associated with a five-digit numeric code. CPT is the industry's standard.
Place of Service: Refers to the physical location where healthcare services are delivered.
Point-Of-Service (POS) Plan: A type of health insurance plan that allows the insured to choose to obtain care from a participating or non-participating care provider. Point-of-service is offered in various delivery systems that include HMOs and PPOs.
Pool: Refers to a defined revenue account. The risk pool defines claim liabilities of a specified account, which is required to support claim liability.
Pooling: Refers to the process of combining for group members.
Portability: A plan of benefits that may be accessed via a national network of providers. Portability is associated with HIPAA and pertains to the ability to eliminate limitations for pre-existing conditions of proof is provided of previous coverage.
Practice Guidelines: Refers to medical practice statements designed to assist the medical practitioner in decisions that are associated with patient care. These guidelines are also employed by managed care organizations to evaluate the medical necessity of treatments.
Pre-Authorization: Scroll to Prior Authorization
Pre-Admission Certification: Assesses the need for inpatient hospital care. It is determined before admission is provided. Evaluation criteria is also used to qualify the appropriateness of patient care.
Pre-Certification: See Prior Authorization.
Pre-Existing Condition: A medical condition that was diagnosed prior to an individual's effective insurance coverage date. Pre-existing conditions may not typically be eligible coverage for between 6 and 12 months. Owing to HIPAA, an individual only need satisfy this waiting period once as long as they carry a group health insurance plan with a single or multiple carriers.
Pre-existing Condition Clause: Refers to an insurance plan that specifies when and if benefits will be paid for a pre-existing condition. This clause may limit treatment for the condition until a certain time period has passed.
Pretax Benefits: Refers to tax-free money set aside by both employers and employees for retirement expenses as well as healthcare costs.
Preferred Provider Organization (PPO): A program of health insurance that contracts with medical care providers. Physicians in these plans are referred to as preferred providers. Enrollees are encouraged to use these providers to achieve lower costs for healthcare. While enrollees may be allowed coverage from non-participating providers, they are typically offered on an indemnity basis. PPO plans are offered as insured or may be self-funded.
Preferred Providers: Refers to the hospitals and healthcare providers that are contracted to deliver healthcare services to members of a health coverage plan. See also Preferred Provider Organization.
Premium: The amount owed/paid to an insurer for provider contractual coverage for healthcare. Usually, premium rates are pre-established in accordance with classifications such as single coverage, family coverage, or employee and child coverage.
Prepaid Group Practice: Refers to a type of HMO plan where healthcare providers deliver medical services / treatments for a fixed payment that has been negotiated in advance.
Prescription Drug Plans: Refers to prescription medication coverage. For hospital inpatients, prescriptions drugs are covered under other hospital charges.
Prescription Medication: Refers to a Food and Drug Administration-approved drug that can only be prescribed by a licensed practitioner of medicine and dispensed by a licensed pharmacy.
Preventive Care: Refers to healthcare that serves to prevent illness or provide early detection of an illness in order to treat it in its earliest stages. Typically, preventative care includes a physical exam and immunizations.
Preventive Services: Refer to routine exams and healthcare treatments designed to prevent illness or detect illness in its early stages.
Primary Care: Refers to basic healthcare treatments that are often provided by general medical practitioners like family doctors and pediatricians.
Primary Care Network (PCN): Refers to a group of primary care doctors that join together to provide contractual care to enrolled individuals.
Primary Care Physician (PCP): Refers to a doctor who practices general medicine, family practice, or pediatrics. Depending on the type of coverage offered, a gynecologist or obstetrician may also be regarded as a PCP.
Primary Coverage: This is a type of coverage that pays for healthcare costs without considering other insurance coverage.
Principal Diagnosis: A health condition that is thought to be responsible for a patient seeking treatment or requiring hospitalization.
Prior Authorization: Refers to the obtaining of pre-approval for healthcare coverage. Prior authorization is not a guarantee of insurance coverage, however.
Product: Refers to a benefit plan. A product may be purchased by an individual or an employer for the purpose of obtaining insurance coverage.
Professional Review Organization (PRO): Refers to a physician-sponsored entity that reviews medical services extended to patients. These reviews are needed to determine the appropriateness of medical treatments.
Prospective Payment Assessment Commission (ProPAC): See Medicare Payment Assessment Commission
Prospective Rating - See Adjusted Community Rating
Prospective Reimbursement: The method employed for paying hospitals or healthcare providers according to contractual agreements.
Provider: Refers to a hospital, physician, pharmacy, group practice, or nursing home to deliver healthcare service.
Provider Profiling: Refers to system employed to track data in order to formulate a clinical picture of physician performance. The goal of this profiling is to develop practices that improve patient care.
Provider Report Card: Refers to a type of tool that interprets the performance of healthcare providers. The report card lists items such as accountability, consumer satisfaction, and quality of medical care. Report cards may be used performance incentive programs for physicians.
Provider Service Network (PSN): See Provider Sponsored Organization.
Provider Sponsor Organization (PSO): Refers to physician groups that coordinate the delivery of medical services. PSOs are structured in various ways. Some may be physician owned while others may be physician practices that are owned by hospitals. A PSO is also referred to as a provider service network (PSN).