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Websites:  https://www.opm.gov/healthcare-insurance/insurance-glossary/

These definitions are for us in HL7 FHIR data standards and assumes no legal or regulatory meaning


Nomenclature

/Concepts

FHIR element

Related Terms

aka

Definition

Notes/Links               

Who

Patient






Laurie
Provider




Sonja

Policy

 


Contract

Legal agreement between a policy holder and an insurer to outline the terms and conditions for certain services rendered  to covered parties

FromDefinition
CCIIO Regs§ 150.103 Definitions.
* * * * *
Individual health insurance policy or individual policy means the legal document or contract issued by the issuer to an individual that contains the conditions and terms of the insurance. Any association or trust arrangement that is not a group health plan as defined in § 144.103 of this subchapter or does not provide coverage in connection with one or more group health plans is individual coverage subject to the requirements of parts 147 and 148 of this subchapter. The term ‘‘individual health insurance policy’’ includes a policy that is –
(1) Issued to an association that makes coverage available to individuals other than in connection with one or more group health plans; or
(2) Administered, or placed in a trust, and is not sold in connection with a group health plan subject to the provisions of parts 146 and 147 of this subchapter.
Merriam Webster: a document that contains the agreement that an insurance company and a person have made
Business DictionaryFormal contract-document issued by an insurance company to an insured. It (1) puts an indemnity cover into effect, (2) serves as a legal evidence of the insurance agreement, (3) sets out the exact terms on which the indemnity cover has been provided, and (4) states associated information such as the (a) specific risks and perils covered, (b) duration of coverage, (c) amount of premium, (d) mode of premium payment, and (e) deductibles, if any.

Read more: http://www.businessdictionary.com/definition/insurance-policy.html

An insurance policy is a contract which outlines an insurer’s obligations to a premium-paying party, known as the policy holder.

What is an Insurance Policy? (with pictures) - wiseGEEK
www.wisegeek.com/what-is-an-insurance-policy.htm


Insurance Policy — in broad terms, the entire printed insurance contract. Generally, an insurance policy is assembled with a combination of various standard forms, including a declarations page, coverage form, and endorsements. Sometimes a causes of loss form is also required. Together these forms delineate the coverage term, the insurance policy limits, the grant of coverage, exclusions and other limitations of coverage, and the duties and responsibilities of the insured in the event of a loss.

The legal document issued by the company to the policyholder, which outlines the conditions and terms of the insurance; also called the policy contract or the contract


 

Mary Kay

Patient

 


 

 An individual who has received, is receiving or intends to receive health care services.

(Health care services as defined by federal and state regulations.)

 NUCC

Not defined by NAIC

Laurie/1st Pass

Provider

 


 

 

 

Sonja

Types of Insurance

 


 

 

TypeDescription
Agricultural

Automobile

Casualty

Deposit

Flood

Health
(includes Dental, Vision)


Home Owner/ Residential

Liability

Life & Annuity

Mortgage

Pet

Property

Reinsurance
(Excessive Loss)


Self

Travel

Worker's Compensation

Focus on Healthcare

Mary Kay

Policy Holder

 


 

 The individual or organization which has contracted with the insurer to provide insurance for health services for a defined group or a named list of beneficiaries.

 

Paul

Insured


The party(ies) covered by an insurance policy.NAIC definitionGail/Laurie

Subscriber

 

Member

 

 An individual or entity that selects benefits offered by an entity, such as an employer, government, or insurance company.



Gail/1st Pass

Subscriber Id

 


 

 

 

Gail

Dependent

 

Member

 

 An individual, other than the subscriber, who has insurance coverage under the benefits selected by a subscriber.  


Gail/1st Pass

Dependent Id

 


 

 

 

Gail

Member

 

Subscriber, Dependent

 

 Any individual covered by the benefits offered by an entity, such as an employer or insurance company.

 

Laurie/1st Pass

Member Id

 


 

 

 

Laurie

Beneficiary

 


 

Any individual covered by the benefits offered by government programs - Medicare????

 

Linda

Period (eligibility)

 


 

When policy in force

? Coverage

Gail

Payor

 


 

 

 

David

Class

 


 

 

 

Serafina

-Group

 


 

 

 

 

-Subgroup

 


 

 

 

 

-Plan

 


 

 

 

Robin

-Subplan

 


 

 

 

 

-Class

 


 

 

 

 

-Subclass

 


 

 

 

 

-Sequence

 


 

 

 

 

-Rxbin

 Rxbin

BIN ANSI Issuer Identification Number (IIN)

Rx bin

Rxbin

RxIIN

BIN Number

 

RxBin - Stands for bank identification number, though it doesn't involve banks and is used to accurately route claims to pharmacy benefit managers (PBM).

The pharmacy industry uses RxBin (required), RxPCN (situational) and RxGrp (situational) to identify pharmacy benefit plans.

RxBIN and RxPCN is analogous to the U.S. zip code + 4. RxBIN (or BIN number), is like the 5-digit zip code that determines the routing destination, and RxPCN (or processor control number), is like the +4, providing a more specific destination.

NCPDP Processor ID Number (BIN) is a six-digit number that health plans use to process electronic pharmacy claims if the health plan doesn't use pharmacy benefit cards with a magnetic stripe. Plans that use cards with a magnetic stripe should use the recommended American National Standards Institute (ANSI) Issue Identifier Number (IIN) for processing electronic pharmacy claims. ANSI issues IIN numbers. NCPDP issues the Processor ID Number (BIN).

Prescription drug routing information, known as 4Rx data, are the four data elements used to process a pharmacy claims.

In Medicare Part D, these four elements uniquely identify the Medicare Part D Sponsor for the beneficiary and are identified by the sponsor during beneficiary enrollment.

The set of four elements are exchanged with CMS contracted entities during eligibility verification, claims processing, and information reporting transactions, as well as post adjudication claim reporting functions.

The 4Rx data are: RxBIN, RxPCN, RXGRP & RxID. 4Rx data allows payment on behalf of the beneficiary to be counted toward TrOOP. (True Out-of-Pocket costs paid by a beneficiary or others on the beneficiary’s behalf that accumulate towards the annual out-of-pocket threshold)

https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/NCPDP-Pharmacy-Identification-Specifications-Information.pdf

NCPDP BIN: https://ncpdp.org/Resources/NCPDP-Processor-ID-(BIN)

ANSI IIN: https://www.ansi.org/other_services/registration_programs/iin

NCPDP Guidance Documents: https://ncpdp.org/Resources/Guidance-Documents.aspx

NCPDP Pharmacy Card Fact Sheet: https://ncpdp.org/NCPDP/media/pdf/NCPDPpharmacyIdCardFactSheet.pdf

Mapping NCPDP Pharmacy Card to X12N 270/271 (eligibility): https://ncpdp.org/NCPDP/media/pdf/Rx_id_card_map_to_270-271.xlsx

NCPDP Medicare Part D Resources: https://ncpdp.org/Resources/Medicare-Part-D

Serafina

-Rxpcn

 Rxpcn

Processor Control Number

 

RxPCN - the Processor Control Number is a secondary identifier used in routing of pharmacy transactions (as noted above, and analogous to the +4 of a nine digit Zip Code +4.

A PBM/processor/plan may choose to differentiate different plans/benefit packages by assigning unique PCNs to them.

PCN is alphanumeric and assigned by PBM/processors making this identifier unique only to their business and there is no registry of PCNs.

The PCN appears on the pharmacy ID card with the BIN/IIN in accordance with rules defined in the NCPDP Pharmacy ID and Combination Card Implementation Guide. This document is available with NCPDP membership. General information is available on the Guidance Documents page under the "Pharmacy and Healthcare Identification Cards" banner.

Not all entities use the PCN to differentiate plans. Some entities may use the Group ID; still others may not need this level of differentiation.

Serafina

-Rxid

 


 

For members who have Medicare part D, this is the patient's member number in the PBM’s system that processes claims

 

Serafina

-Rxgroup

 


 

Each Pharmacy Benefit Manager has many groups. Rxgroup identifies the group in which the member is enrolled so claims can be process efficiently and correctly. 

 

Serafina

Program

 


 

280.3 For the purposes of the Federal Program Inventory, what is a program?
GAO defined program in the Glossary of Terms Used in the Budget Process as an organized set of activities directed toward a common purpose or goal that an agency undertakes or proposes to carry out its responsibilities. Within this broad definition, agencies and their stakeholders use the term “program” in different ways. Agencies have widely varying missions and achieve these missions through different programmatic approaches, so differences in the use of he term “program” are legitimate and meaningful.
For this reason, this guidance does not prescribe a superseding definition of “program”; rather, consistent with the GPRA Modernization Act, agencies may identify programs consistent with the manner in which the agency uses  programs to interact with key stakeholders and to execute its mission.

 OMB Circular No. A–11 (2015)
AND/or
AO-05-734SP A Glossary of Terms Used in the Federal Budget Process

Tony

Product

 


 

 

 

 

Order

 


 

 The order of application of the insurance to health care claims relative to the other insurance policies (Coverages) which an individual may have. This order would generally follow the order convention for Coordination of Benefit and would include consideration of both health care and accident based insurance. 

? Account Coverage.priority

Paul

Network

 


 

 

 

Bob

Copay

 


 

 

 

 

-GP Office Visit Copay

 


 

 

 

 

-Specialist Office Visit Copay

 


 

 

 

 

-Emergency Copay

 


 

 

 

 

-Inpatient Hospital Copay

 


 

 

 

 

-Tele-visit Copay

 


 

 

 

 

-Urgent Care Copay

 


 

 

 

 

-Copay Percentage

 


 

 

 

 

-Copay Amount

 


 

 

 

 

-Deductible

 


 

 

 

 

-Maximum Out of Pocket

 


 

 

 

 

-CoInsurance

 


 

 

 

 

Exception

 


 

 

 

 

-Retired Exception

 


 

 

 

 

-Foster Exception

 


 

 

 

 

Subrogation

 


 

 

 

 

Contract

 


 

 

 

 

Contract ID?

 


 

 

 

 

Type

 


 

 

 

 

 

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