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  Agent An independent representative licensed to sell and service HealthSpring plans.  
     
  Allowed amount The dollar amount that a health plan determines is appropriate for a covered service. HealthSpring network healthcare providers have agreed to accept the allowed amount as full payment, which means you pay less for your care.  
     
  Allergist A specialist who studies allergies, or the body's reaction to substances, situations, or physical states that don't affect the average person.  
     
  Anesthesiology A branch of medicine that involves pain management and support of a patient's life functions during anesthesia and surgery.  
     
  Appeal A formal request by a member or healthcare provider to reconsider a decision about a service, a benefit payment or an administrative action.  
     
  Audiology A branch of science dealing with hearing.  
     
  Behavioral health care The practice of evaluating and treating mental health, chemical dependency disorders, autism and eating disorders.  
     
  Cardiology Diagnosis and treatment of diseases of the heart and blood vessels.  
     
  Cardiovascular disease A disease relating to, or involving, the heart and blood vessels.  
     
  Case manager An experienced healthcare professional (nurse, doctor or social worker) who works with patients, providers and plans to coordinate care for individual patients.  
     
  Chiropractic Treatment to restore normal function through manipulation and adjustment; particularly of the spinal column.  
     
  Claim Information provided by a healthcare provider or a member to establish that medical services were provided.  
     
  Coinsurance The percent of covered healthcare costs that a member pays.  
     
  Coordination of benefits If a member is eligible to receive benefits under this plan and another group plan, we’ll coordinate benefits with the other plan. Coordination of benefits means one plan pays first (is primary) and one plan pays second (is secondary). This prevents overpayment of charges. When coordinating benefits, the total payment to a healthcare provider will not be more than 100 percent of the covered cost.  
     
  Copay A payment, usually a fixed amount, that you make on a per-service basis.  
     
  Credentialing The process of reviewing providers who apply to participate in a health plan to make sure they meet the plan's requirements.  
     
  Deductible The annual amount you pay toward eligible healthcare services each year before your health plan pays on your behalf.  
     
  Dermatology Diagnosis and treatment of disorders of the skin.  
     
  Diagnostic services X-ray, laboratory and pathology services that help diagnose or treat an illness or injury.  
     
  Durable medical equipment Medical equipment that is able to withstand repeated use and is used primarily for a medical purpose. Examples are wheelchairs, crutches and hospital beds. It is not equipment that would be useful to a person who isn't sick or that would otherwise be useful in the patient's home.  
     
  Eligibility The conditions a person must satisfy to be covered by the health plan contract.  
     
  Eligible charges Services that are covered according to the health plan contract.  
     
  Emergency A sickness or injury so serious that failure to get immediate care could put a person's life in danger or cause serious harm. Some examples are possible heart attack (severe chest pain or pressure), uncontrollable bleeding, breathing problems, poisoning and unconsciousness.  
     
  Endocrinology A science dealing with the endocrine glands, which produce secretions that help control metabolic activity.  
     
  Experimental procedures Any services, supplies, treatments, procedures or devices that are determined by the health plan to be not generally accepted by informed healthcare professionals in the United States as effective in treating the condition for which their use is proposed or not scientifically proven to be effective in treating the condition.  
     
  Explanation of health care benefits (EOB) A notice sent from the health plan to the member describing the resolution of a claim. It includes services provided, amount billed, payment made and any costs that are the member's responsibility.  
     
  Family practice A medical specialty that focuses on healthcare for the entire family, including obstetric care and minor surgical procedures.  
     
  Gastroenterology Diagnosis and treatment of stomach, intestine, liver and pancreas diseases.  
     
  General practitioner A physician who does not limit his or her field of practice to a specialty.  
     
  Geriatrics Diagnosis and treatment of diseases and conditions specific to aging.  
     
  Gynecology Medical and surgical treatment for disorders and diseases of the female reproductive and urinary systems.  
     
  Health care provider A hospital, clinic, physician or other facility that provides healthcare services.  
     
  Health risk assessment A confidential tool that helps employees identify their individual health risks and offers suggestions to reduce those risks.  
     
  Home health care Services provided in the home to aged, disabled, sick or convalescent people who don't require institutional care. Services are provided by a home health agency, visiting nurse, or other hospital or community group.  
     
  Hospice A facility or program that provides supportive care for people who are terminally ill.  
     
  ID card See Member ID card .  
     
  Internal medicine A medical specialty focusing on the prevention, diagnosis and treatment of diseases affecting adults.  
     
  Immunology The study of immunity and immune responses.  
     
  Long-term care insurance Coverage designed to reduce the risk that the contract holder would need to deplete his or her assets to pay for long-term care.  
     
  Medical policy Documentation that provides medical necessity and coverage guidelines for our members.  
     
  Medically necessary Healthcare services and supplies that are evaluated as appropriate and necessary based on diagnosis and cost-effectiveness, and that are consistent with national medical practice guidelines on type, frequency and length of treatment.  
     
  Medicare supplement Supplementary coverage, available to persons eligible for Medicare, to help pay remaining balances after Medicare has made payment.  
     
  Medigap insurance Private insurance policies that supplement Medicare and cover the difference between what Medicare pays and the allowed charges for covered and uncovered services.  
     
  Member A person covered by a health plan.  
     
  Member ID card A card that identifies members of a plan. It lists the identification number, group number and effective date of the plan and includes important phone numbers.  
     
  Neonatology Diagnosis and treatment of disorders in newborns.  
     
  Nephrology Diagnosis and treatment of fluid and electrolyte disorders and hypertension, including disorders of the kidney.  
     
  Network The hospitals, physicians and other medical professionals who sign a contract with a health plan to provide care for its members. Also referred to as participating or in-network providers.  
     
  Neurology Diagnosis and treatment of diseases and injuries of the nervous system (brain, spinal cord, nerves), medically rather than surgically.  
     
  Nurse midwife A licensed healthcare professional who provides gynecological services and care for women during and after normal pregnancy and labor.  
     
  Nurse practitioner A licensed registered nurse who has gained additional knowledge and skills through an organized program of study and clinical experience.  
     
  Obstetrics/gynecology (ob/gyn) The medical specialty that focuses on women's healthcare issues like pregnancy, childbirth, family planning and annual checkups.  
     
  Obstetrics Healthcare during and after a woman's pregnancy.  
     
  Occupational therapy A branch of medicine that involves a program of activities to help patients regain a degree of independence or return to employment.  
     
  Open-access plans Benefit plans that allow members to see network providers for specialty care without a referral from another doctor.  
     
  Open enrollment The period of time when an employee may change enrollment status or benefit plans, usually without evidence of good health or waiting periods.  
     
  Ophthalmology Diagnosis and treatment of glaucoma and muscle disorders of the eye, including cataract surgery and laser treatment, and vision evaluation and prescribing of corrective lenses.

 

  
     
  Oncology The medical science or specialty concerned with the diagnosis and treatment of tumors, commonly various forms of cancer.

 

  
     
  Optometry The art or profession of examining the eye for defects and prescribing corrective lenses or exercises to correct the defect.

 

  
     
  Oral and maxillofacial surgery Diagnosis and treatment of disorders of the mouth, teeth, jaws and facial structures, including surgical correction of facial deformities and fractures.

 

  
     
  Oral surgery Field of dentistry dealing with surgery of the mouth and its related structures.

 

  
     
  Orthopedic surgery A branch of medicine that involves surgical treatment of skeletal deformities and injuries.

 

  
     
  Orthotics Specialized field relating to orthopedic appliances, braces and other devices used to support weight, prevent or correct deformities, or align and improve the function of movable parts of the body.

 

  
     
  Osteopath Similar to medical doctors, osteopaths (also referred to as doctors of osteopathic medicine or DOs) emphasize the role of the bones, muscles, and joints in the healthy functioning of the human body.

 

  
     
  Otolaryngology The diagnosis and treatment, medically and surgically, of diseases and disorders of the ear, nose and throat. Also referred to as ENT.

 

  
     
  Out-of-network The option to see healthcare providers who don't have a contract with the health plan. When benefit plans include this option, members share more of the cost when receiving care from out-of-network providers.

 

  
     
  Out-of-pocket costs The portion of healthcare costs that a member is responsible for, including copays, coinsurance, deductibles and noncovered services.

 

  
     
  Out-of-pocket maximum The most a member must pay each year toward allowed healthcare costs. Once the out-of-pocket maximum is reached, the health plan pays 100 percent until the end of the calendar or benefit year.

 

  
     
  Pediatrics The prevention, diagnosis and treatment of diseases in children, from birth through the teenage years.

 

  
     
  Physiatry The diagnosis, treatment and prevention of disease with the aid of physical agents such as light, heat, cold and water, or with medical apparatus. Physiatry is focused on rehabilitative medicine.

 

  
     
  Physical therapy Treatment of bodily ailments and muscular function through various physical and nonmedicinal means (the use of heat, water, exercise, massage and electric current, for example).

 

  
     
  Physician A licensed doctor of medicine with full training in traditional medical practice. Physicians undergo a broad-based medical school education, extensive experience in residency and a comprehensive series of medical board examinations prior to being licensed.

 

  
     
  Plastic surgery Plastic surgical procedures fall into two major subdivisions: reconstructive procedures, which involve the restoration of form, and in many cases function, of body parts that are abnormal due to injury, disease, or congenital defects, and cosmetic procedures, which are performed to enhance the appearance of body parts which fall within the normal range of appearance and function.

 

  
     
  Podiatry The diagnosis and treatment of disorders of the feet.

 

  
     
  Point-of-service plan A type of benefit plan that lets the member choose health services from in-network primary care or out-of-network healthcare providers at the time care is needed, with different benefit levels.

 

  
     
  Pre-existing condition A condition, injury, or sickness considered to be a condition requiring medical treatment that existed before the effective date of a health plan contract. If a condition is pre-existing, it may not be covered for a specific period of time under some contracts.

 

  
     
  Primary care Basic or general healthcare usually provided by general practitioners, family practitioners, internists and pediatricians.

 

  
     
  Primary care clinic The clinic a member chooses to coordinate his or her health care services.

 

  
     
  Prosthetics The study of artificial limbs — their design, construction and fitting to a patient.

 

  
     
  Provider Any individual or group that provides a healthcare service, such as doctors, hospitals, group practices, nursing homes or pharmacies.

 

  
     
  Psychiatry The study, diagnosis, treatment and prevention of mental illness.

 

  
     
  Psychologist A practitioner of clinical psychology, counseling or guidance.

 

  
     
  Psychotherapy The psychological techniques used in behavioral health care.

 

  
     
  Pulmonary medicine Diagnosis and treatment of lung diseases and conditions such as bronchitis, emphysema and cancer.

 

  
     
  Referral Advance approval from a primary care provider for a patient to see a specialist.

 

  
     
  Radiology A branch of medicine concerned with the use of X-rays and radium in the diagnosis and treatment of disease.

 

  
     
  Rheumatology The diagnosis and treatment of muscle and joint diseases and conditions, particularly arthritis.

 

  
     
  Self-insured plan A benefit plan offered by a company in which the company pays for its employees’ healthcare claims.

 

  
     
  Specialist A doctor with specialized medical training.

 

  
     
  Speech therapy The therapeutic treatment of speech defects, such as lisping and stuttering.

 

  
     
  Sports medicine A medical specialty concerned with the prevention and treatment of injuries and diseases that are related to participation in sports.

 

  
     
  Urology A branch of medicine that involves diagnosis and treatment of diseases and disorders of the kidneys, bladder, and urinary tract. Also includes the treatment of disorders affecting the male reproductive organs.

 

  
     
       

 

 

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