Glossary

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

A paid contract is a type of excess-loss policy that covers claims paid within the policy year, regardless of the date of service.

The term "PDA" means the Pregnancy Discrimination Act.

The term "PHI" means protected health information.

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.

A plan document is a comprehensive and detailed description of the benefits and provisions under which a plan is administered.

A plan sponsor is the entity that establishes and maintains a benefits plan.

A plan year is the 12-consecutive-month period that a plan identifies for keeping records and filing a Form 5500 for tax purposes.

The term "POP" means premium only plan.

The term "PPO" means preferred provider option.

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.

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.

The PDA forbids employers from discriminating against employees on the basis of pregnancy, childbirth, or other related medical conditions.

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.

A PCP is a designated health care professional who diagnoses, treats, and coordinates a covered person's health care needs.

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.

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

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.

Psychiatric care is behavioral or psychoanalytic care.

Psychoanalytic care is behavioral or psychiatric care.