This refers to the amounts paid to providers or members for eligible services.
Paid to date
For a spending account, this is the amount taken from your account to pay medical expenses as of a certain date.
Palliative treatments are services that are intended to relieve pain but not provide a cure.
Part D (Medicare prescription drug coverage)
See the definition for Medicare Part D (prescription drug coverage).
See the definition for Medicare Part A (Hospital Insurance).
See the definition for Medicare Part B (Medical Insurance).
Part C (Medicare Advantage plans)
See the definition for Medicare Part C (Medicare Advantage Plans).
For people with Medicare Parts A and B, these are hospitals that participate in the Medicare program.
Participating physician or supplier
For people with Medicare Parts A and B, this is a doctor or other provider who agrees to accept all Medicare claims. These providers accept "Medicare assignment." They may bill you only for the Medicare deductible and your coinsurance or copayment amounts.
Any provider who is a member of a benefit plan's network is considered a participating provider.
A patient advocate is a person who speaks on a patient's behalf and helps patients get any information or services they need.
See “Personal Care Account”.
PCA rollover balance
Remaining previous plan year's PCA balance that you were allowed to carry over for use during your current plan year. This feature is not available to all.
Primary care dentist.
See the definition for primary care physician.
This refers to primary care physician name. In dental insurance for a DHMO, Humana uses PCD (primary care dentist).
A Prescription Drug Plan, PDP provides seniors and people with disabilities with the first comprehensive prescription drug benefit ever offered under the Medicare program for a monthly premium.
This is a dental specialist whose practice is limited to treatment of children from birth through adolescence.
This dental specialty is concerned with the prevention and treatment of dental disorders in children.
See Pediatric Dentist.
Peer reviews are evaluations of the quality and conduct of healthcare services. They are conducted by professionals with training equal to the provider who performed the treatment.
This term indicates an estimate or a claim that has been received but processing is not complete.
These are claims that have been submitted but not yet paid because additional information is needed.
For a spending account, these are transactions either into or out of your account that have not been completely processed. Transactions may be pending because we need to verify the charge on the HumanaAccess Visa Debit Card.
A dental specialist, a periodontist’s practice is limited to the treatment of diseases of the supporting and surrounding tissues of the teeth.
Permanent and total disability
This refers to a disability that prevents you from working again because of injury or illness.
Permanent mailing address
This is the address where you currently reside. It is considered your primary residence.
Personal Care Account
Personal Care Account - A Health Reimbursement Arrangement (HRA) regulated by the IRS and funded entirely by the employer. You can use PCA funds for qualified medical expenses not covered under the health plan.
This is the percentage of the total cost of your prescription drug that you must pay. When you go to an in-network pharmacy, your coinsurance is based on the Humana-approved charge, which may be less than the original charge.
The amount you pay for a prescription drug is your pharmacy copayment. A copayment can range from a few dollars to a few hundred dollars depending on the type of drug you receive.
Exercise, massage, stretching, applied heat, and other activities are forms of physical therapy used to treat injuries or debilitating illnesses.
Medical professionals who are licensed by the country or state in which they perform or prescribe treatment, physicians can only practice within the scope of their license.
Physician Finder Plus
Here's where you can find out if your doctor is in network. Physician Finder Plus — on Humana.com/members — lets you search for in-network doctors, hospitals, urgent care centers, and other providers of healthcare.
The document that details your dental benefits is a plan certificate.
This is the annual amount you save because of Humana’s negotiated rate with providers (such as doctors, hospitals, etc.).
Plan exclusions are items or services received from a provider that are not covered by your plan.
The amount Humana will pay or has paid for a specific service.
A plan premium is your monthly payment to Humana for healthcare coverage or prescription drug coverage. This cost does not include your Medicare Part A or Part B premiums.
The year starting with your plan effective date is known as your plan year.
A Power of Attorney (POA) is a document that's signed by a member to authorize another party to act on the member's behalf. The Executor of Estate takes the place of a Power of Attorney after a member is deceased and the Executor is appointed. Power of Attorney and Executor of Estate are legal documentation and must be provided before another party can act on the member's behalf.
Point Of Service (POS)
The option under TRICARE Prime that allows enrollees to self-refer for non-emergent health care services to any TRICARE-authorized civilian provider, in or out of the network. When Prime enrollees choose to use the POS option (i.e., to obtain non-emergent health care services from other than their Primary Care Managers [PCMs] or without a referral from their PCMs), all requirements applicable to TRICARE Standard apply except the requirement for a Non-Availability Statement. POS claims are subject to deductibles and cost-shares even after the enrollment/fiscal year catastrophic cap has been met. The POS option is not available to Active Duty Service Members (ADSMs).
These plans permit you to choose providers outside your plan but still encourage you to use network providers.
This is the legal document a benefits insurer issues to the policyholder, which outlines the conditions and terms of the benefits. It is also called the policy contract or the contract.
The period for which a benefits policy provides coverage for eligible employees is the policy term.
Portability is a component of HIPAA that protects coverage for workers and their families when they change or lose their jobs. It also prevents discrimination against employees and their families due to preexisting medical conditions.
Portability allows an active eligible employee who leaves the group to continue coverage by paying annual premiums to Humana if he or she is not yet age 70. Only coverage in force or a lesser amount can be ported at termination.
Portability (Voluntary Life)
Humana Voluntary Life is portable subject to plan provisions. An active eligible employee who leaves the group can continue coverage by paying annual premiums to Humana if he or she is not yet age 70. Only coverage in force or a lesser amount can be ported at termination.
For a spending account, these are transactions that have been verified and applied to your account.
Power of attorney
A medical power of attorney is a document that lets you appoint someone you trust to make decisions about your medical care. This type of advance directive also may be called a healthcare proxy, appointment of healthcare agent, or a durable power of attorney for healthcare.
PPO is short for a Preferred Provider Organization, a type of health plan that gives you the freedom to choose your own doctors and hospitals. However, your out-of-pocket costs are usually lower if you choose healthcare providers who participate in the plan's network.
See the definition for Preferred Provider Organization (PPO).
This statement by a third-party payer indicates the proposed treatment that will be covered under the terms of the contract.
Pre-certification is a third-party payer's confirmation that you are eligible for coverage under a benefit program.
In this process, the provider submits a treatment plan to the third-party payer before treatment is begun. In response, the third-party payer notifies the provider and patient of the covered services, benefits payable, copayments, deductibles and plan maximum.
A condition you had and were advised of before obtaining health insurance with Humana is a pre-existing condition. In some cases, there's a waiting period before this condition will be covered by your insurance.
Preferred brand drug
This is a brand-name medication on Humana’s formulary that may be priced lower since it is preferred.
Preferred generic drug
These are drugs on your formulary that are the equivalent of brand name drugs with the same chemical makeup. These medications have the same risks and benefits as brand name versions: they are as safe, have the same active ingredients, are prescribed at the same dosages, and are used to treat illnesses in the same way. However, a generic drug is called by its "chemical" name instead of a "brand" name and is typically sold at a lower price. In most cases, your doctor can prescribe a generic drug instead of the brand-name, allowing you to save on your prescriptions.
This is a network pharmacy where covered Part D drugs are offered at negotiated prices with cost-sharing levels that are lower than those at non-preferred pharmacies.
Providers who contract to provide health services to persons covered by a particular health plan are preferred providers.
Preferred Provider Organization - PPO (Medicare)
A PPO is a Medicare Advantage plan that gives you two ways to receive medical services. You can use doctors, hospitals, and other healthcare providers in the plan's network and pay less for your care. Or you have the option of going outside the network, but you will pay more for your healthcare services. Get more information on HumanaChoicePPO plans.
Preferred Provider Organization (PPO)
PPOs are managed care organizations that offer certain methods to deliver services, such as networks of providers. Under a PPO benefit plan, covered individuals retain the freedom to choose providers but are given financial incentives (i.e. lower out-of-pocket costs) to use the preferred provider network.
A premium is what you pay for healthcare coverage. Premiums are usually paid monthly to Medicare, an insurance company, or a healthcare plan.
Prepaid dental plan
This is a method of financing the cost of dental care before you receive services.
Prescription drug guide
This guide is a list of the medications covered by Humana's prescription drug benefits. See the definition of drug list.
Prescription Drug Plan (PDP)
PDPs is optional Medicare drug coverage offered through private insurance companies. It is also known as Medicare Part D. You must pay a monthly premium for a PDP in addition to any Medicare premium you already pay. PDP plan benefits vary, but companies offering these plans are required to provide benefits as good as or better than Medicare's standard requirement.
With this type of care, there is an emphasis on preventing health problems before they occur.
These are dental procedures concerned with the prevention of dental diseases by protective and educational measures. They may include an examination, cleanings, X-rays, and fluoride treatments.
This basic level of care is usually provided by doctors or nurse practitioners who work in general and family medicine, internal medicine, prenatal medicine, and pediatrics.
Primary care doctors
Most plans consider the following doctors to provide this basic level of healthcare: general practitioner, family medicine doctor, obstetrician, pediatrician, and, sometimes, a nurse practitioner.
Primary Care Manager (PCM)
An MTF provider, team of providers, or a network provider to whom a beneficiary is assigned for primary care services at the time of enrollment in TRICARE Prime. Enrolled beneficiaries agree to initially seek all non-emergency, non-behavioral health care services from their PCMs.
Primary care physician (PCP)
Your PCP is the doctor you see first for most health problems. PCPs make sure that you get the care you need to stay healthy. They may consult with other doctors and healthcare providers about your care and refer you to them. In many Health Maintenance Organization (HMO) plans, you must see your primary care physician before you see any other healthcare provider.
This refers to coverage that pays expenses first, whether or not there is any other coverage. See Coordination of Benefits.
Prime Service Area (PSA)
The geographic area where TRICARE Prime benefits are offered. This includes all catchment areas, Base Realignment, and Closure Commission sites; a 40-mile radius around all military treatment facilities; and all additional areas proposed by the regional managed care support contractor.
Your doctor must obtain approval from Humana before a specific service or prescription will be covered. This is known as prior authorization.
This is something done to fix a health problem or to learn more about your condition. Types of procedures include surgery, tests, or starting an intravenous line.
To divide, distribute, or assess based on proportion is to prorate.
This dental specialty is concerned with the restoration of missing teeth by artificial means.
A dental specialist, a prosthodontist’s practice is limited to the restoration of the natural teeth and/or the replacement of missing teeth with artificial substitutes.
Protected Health Information (PHI)
Protected Health Information is made up of two components: Health Information and Individually Identifiable Health Information. Health Information is information that relates to the past, present, or future health of the individual; the provision of healthcare to an individual; or the past, present, or future payment for the provision of healthcare. Individually Identifiable Health Information is information that can be used to identify the individual, such as a name or social security number.
A person or facility that offers healthcare services is called a provider. Providers may include a doctor, hospital, skilled nursing facility, home health agency, outpatient physical therapy, comprehensive outpatient rehabilitation facility, end-stage renal disease facility, hospice, non-physician provider, laboratory, supplier, etc. Generally, providers are licensed or certified and must practice within the scope of their license or certification.
The name of the treating doctor, hospital, or other healthcare provider.
A benefit plan sponsor, a purchaser is often an employer or a union that contracts with the benefit organization to provide benefits.