Glossary

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An evaluative process in which a healthcare organization undergoes an examination of its policies and procedures to determine whether the procedures meet designated criteria as defined by the accrediting body, and to ensure that the organization meets a specified level of quality. A member that currently has coverage with GHI. The amount a physician or other practitioner actually bills a patient for a medical service or procedure. A traditional Chinese medical practice of insertion of fine needles into specific exterior body locations to relieve pain, to induce surgical anesthesia, and for therapeutic purposes. A physical condition or illness that begins abruptly and requires medical care or restricted activity for a short period of time (usually 3 months or less). The process by which a claim is paid or denied based on eligibility and contract determination. Formal acceptance as an inpatient by an institution, hospital or healthcare facility. The physician responsible for admission of a patient to a hospital or other inpatient health facility. A determination by GHI or its agents that an admission, extension of stay or other health care service has been reviewed and, based on the information provided, is not Medically Necessary. American Osteopathic Association (AOA) certification agent organized in 1939 for the purpose of establishing and maintaining standards of osteopathic specialization and pattern of training. The treatment of the allergic patient may include identifying the offending agent by means of various testing methods. Once the agent is identified, treatment is provided by avoidance, medication, or immunotherapy. The Allowed Charge is the amount GHI will reimburse you for covered services rendered by non-participating Providers. All types of health services that are provided on an outpatient basis. A medical care center that provides a wide range of healthcare services, including preventive care, acute care, surgery and outpatient care in a centralized facility. Surgical procedures performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called Outpatient Surgery. Organized originally in 1933 as the Advisory Board of Medical Specialties, the ABMS (1970), in collaboration with the American Medical Association (AMA), is the recognized certifying agent for establishing and maintaining standards of medical specialization and pattern of training. Auxiliary or supplemental services (i.e. diagnostic services, physical therapy, medications) used to support diagnosis and treatment of a patient's condition. The maximum accumulated payments GHI will make for covered services rendered to a covered person during a calendar year, or the maximum number of covered days/visits available to a covered person for a particular service or services during a calendar year. A process used by a provider or member to request the health plan reconsider a previous adverse determination. An agreement in which a patient assigns to another party, usually a physician or hospital, the right to receive payment from a public or private insurance program for the service the patient has received. Physician primarily responsible for the care of a patient during hospitalization. Services which have been approved for payment based on a review of GHI's policies.