These terms are defined for general information purposes only; certain terms may have varying definitions based on state law.
- A
- Aexcel
- Aexcel is a physician designation within Aetna's Performance Network that includes specialists who have demonstrated effectiveness in the delivery of care based on a balance of measures of clinical performance and efficiency.
- Allowable Expense
- Any necessary and reasonable health expense, part or all of which is covered under any of the plans covering the Member for whom claim is made.
- B
- No entries for this letter
- C
- Capitation
- The prepaid amount which the provider receives as compensation for Capitation Services.
- Case Management
- A process of identifying individuals at high risk for problems associated with complex health care needs, assessing opportunities to coordinate care, control costs and manage a member's full spectrum of care to optimize outcome.
- Coinsurance
- The portion of covered expenses which a member must pay for care, after first meeting a deductible amount, if any.
- Coordination of Benefits (COB)
- A provision that is intended to avoid claims payment delays and duplication of benefits when a person is covered by two or more plans providing benefits or services for medical, dental or other care or treatment. It avoids claims payment delays by establishing an order in which plans pay their claims and providing the authority for the orderly transfer of information needed to pay claims promptly. It may avoid duplication of benefits by permitting a reduction of the benefits of a plan when, by the rules established by this provision, it does not have to pay its benefits first. Refer to the Coordination of Benefits section of your applicable plan document.
- Copayment
- A charge required under a Plan that must be paid by a Member at the time of the provision of Covered Services.
- Credentialing
- A systematic approach to assessing the qualifications of potential and existing providers through a review of relevant training, experience, licensure, certification, and/or registration to practice in a health care field; includes review of historical records to ascertain that potential providers have the required academic background and an acceptable record on issues relating to professional competence and conduct.
- D
- Deductible
- An amount that a Member must pay for Covered Services per specified period in accordance with the Member's Plan before benefits will be paid.
- Dependent
- A person other than the enrollee who is eligible to receive care under a plan's provisions. Examples would be a spouse or child.
- Direct Access
- Under certain Aetna®plans, you (the member) may have “direct access” (sometimes referred to as “open access”) to any participating provider of a specified specialty without a referral.
- DocFind®
- You can research participating physicians, hospitals, dentists, pharmacists and other providers in your area through DocFind, Aetna's electronic provider directory (updated weekly) on our website. DocFind also allows you to obtain other useful information, such as where a physician went to medical school and whether he/she is board certified.
- Drug Formulary
- A listing of prescription drugs and insulin established by the health plan which includes both Brand Name Prescription Drugs, and Generic Prescription Drugs. This list is subject to periodic review and modification by the health plan. Drugs listed on the formulary are covered under our managed prescription drug plans, with copayments that may vary based on plan design. Certain non-formulary drugs are also covered under some plan designs.
- E
- Emergency
- Emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in (I) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman and her unborn child) in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious dysfunction of any bodily organ or part.
- Explanation of Benefits
- For certain Aetna plans, an Explanation of Benefits form is provided to members to explain how the payment amount for a health benefit claim was calculated. Among other things, the Explanation of Benefits may explain the claims appeal process.
- F
- No entries for this letter
- G
- No entries for this letter
- H
- Health Insurance Portability and Accountability Act (HIPAA)
- HIPAA is a federal law enacted in 1996. It was designated to improve availability and portability of health coverage by:
- limiting exclusions for pre-existing conditions;
- providing credit for prior health coverage;
- allowing transmittal of the coverage information (i.e., covered family members and coverage period) to a new insurer;
- providing new rights to allow individuals to enroll for health
coverage when they lose their health coverage or have a new dependent;
- prohibiting discrimination in enrollment/premiums
- guaranteeing availability of health insurance coverage for small employers.
- Health Maintenance Organization (HMO)
- Aetna offers various HMO plan designs with varying copayments. Except for direct access programs, emergency situations and for out-of-area urgent care, members may access health care services only through their chosen primary care physician (PCP). The PCP coordinates all aspects of a member's care covered under the plan. Specialty or facility services are not covered unless approved or directed in advance by the member's PCP.
- I-L
- ID Card
- Your Aetna member ID card provides proof of your Aetna coverage. An ID card is sent to you after we accept your enrollment form. As of your effective date, your copy of the enrollment form may be used as a temporary membership card until you received your permanent card. Your Aetna ID card includes your member identification number, as well as your toll-free phone number to contact Aetna Member Services. If you need to request a new ID card, you may do so through our Member Services page.
- Indemnity Plan
- A traditional indemnity plan allows members flexibility in their choice of recognized health care providers. Members are responsible for seeking care, initiating precertification, paying for services rendered, and submitting claims for reimbursement of covered services at a predetermined coinsurance rate.
- Independent Practice Association (IPA)
- A legal entity or other group of providers that contract with managed care plans while maintaining their separate practice. A member who selects an IPA-affiliated primary care office generally will be referred to specialists and hospitals affiliated with the IPA, unless the member's medical needs extend beyond the capability of these providers.
- InteliHealth®
- Aetna’s online health affiliate. This site offers valuable information about current health issues, fitness tips and health-related products.
- M
- Member Services
- The Aetna Member Services department assists members with questions about plan benefits and, if applicable to your plan, selecting or changing a primary care physician (PCP). Calling the toll-free number on your ID card will connect you with your plan's Aetna Member Services office. If you do not have your ID card yet, contact your employer's benefits office for your Member Services toll-free number.
- N
- National Advantage Program (NAP)
- The National Advantage Program (NAP) offers access to contracted rates for many medical claims that would otherwise be paid as billed under many indemnity plans, the out-of-network portion of managed care plans, or for emergency/medically necessary services not provided within the standard network. The NAP Network consists of many of Aetna's directly-contracted hospitals, ancillary providers, and physicians. The Network also includes hospitals, ancillary providers, and physicians accessed through vendor arrangements where Aetna does not have direct contractual arrangements. Aetna does not credential, monitor or oversee those providers who participate through third party contracts. Since there are a number of factors that determine whether a discount will be given, Aetna is unable to guarantee any level of discount under this program.
- National Committee for Quality Assurance (NCQA)
- The National Committee for Quality Assurance (NCQA) is an independent, not-for-profit organization that evaluates HMO plans. The NCQA accreditation process is nationally recognized and evaluates how well a health plan manages all aspects of its medical delivery system and the extent to which it continuously improves health care for its members.
- National Medical Excellence Program
- Through this unique program, Aetna gives eligible members access to nationally respected physicians and facilities if a particularly complicated condition cannot be treated within the service areas. If your recommended treatment program meets the criteria for care outside your service area, your primary care physician or specialist will submit your case for review to determine where the appropriate treatment is available. Aetna will pay for your care (less applicable copayments) as well as related transportation expenses. There is also an allowance for a companion to accompany you.
- Network
- Physicians, hospitals and other health care providers who contract with Aetna to participate in health benefits plans. For certain Aetna plans, a member must access care through the network to receive the maximum level of benefits.
- O
- Outpatient
- Care provided in a clinic, emergency room, hospital or non-hospital surgical facility ("SurgiCenter") without admission to the hospital or facility.
- P-Q
- Participating Provider
- Any physician, hospital, skilled nursing facility, or other individual or entity involved in the delivery of health care or ancillary services which contracts to provide Covered Services to Members.
- Plan Documents
- Plan documents include the Group Agreement, Group Policy, and Certificate or Evidence of Coverage (or Certificate of Insurance).
- Point-of-Service Plan
- A point of service plan provides benefits for covered services received from both participating and non-participating providers. When you enroll in a point-of-service plan, you choose a primary care physician (PCP) for yourself and each covered dependent. In order to receive the higher level of benefits under the plan, you must access care through your PCP, except for emergency care or direct access benefits. Your are responsible for a copayment. Care received on a self-referral basis may be subject to a reduced level of benefits than care accessed through your PCP, except for direct access benefits. You are responsible for a deductible and coinsurance percentage for self-referred services.
- Preauthorization / Precertification
- For certain Aetna plans, you must obtain authorization from Aetna prior to receiving certain non-emergency medical services.
- Preferred Provider Organization (Open Choice®):
- Aetna's preferred provider organization (PPO) plan is called Open Choice. Members may choose any health care providers; however, they generally receive a higher benefit level if they choose an Aetna participating provider. Members do not identify a primary care physician to manage their care and can self-refer to providers either in or out-of-network.
- Primary Care Physician:
- A Participating Physician whose area of practice and training is family practice, general medicine, internal medicine or pediatrics, or who is otherwise designated as a Primary Care Physician (“PCP”) by Company. A PCP has agreed to provide primary care services and to coordinate and manage all Covered Services for Members who have selected such Participating Physician, if the applicable Plan requires a Primary Care Physician for maximum reimbursement of covered benefits.
R
- Referral
- Specific directions or instructions from a Member's PCP, in conformance with HMO's policies and procedures, that direct a Member to a Participating Provider for Medically Necessary care.
- S
- Specialist
- A Physician who provides medical care in any generally accepted medical or surgical specialty or subspecialty.
- T-Z
- No entries for these letters
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