Glossary

Reimbursement Terms

Allowable Charge: This is the largest amount an insurer will pay for a specific supply or service. It is also known as the reasonable and customary charge.

Assignment of Benefits: In most cases, certain benefits can be paid directly to a provider, once the insured person signs a transfer form approving this.

Beneficiary: A person who can receive benefits under a health care plan.

Benefits Summary: A summary of the services that a plan, whether an insurance company, self-funded employer or managed care organization, will provide to an insured member. This also refers to covered services as defined by the contract or policy.

Carrier: The company that writes and/or administers an insurance plan.

Centers for Medicare and Medicaid Services (CMS) 1500 Form: Formerly known as Health Care Financing Administration (HCFA) 1500 Form. The standard claim form for a doctor's health care services.

Deductible: A fixed annual amount that a patient must pay before insurance benefits cover services or procedures. Deductible amounts vary widely by insurer and plan type.

Claim: A bill that is submitted by a patient or health service provider to an insurer requesting payment for eligible services or prescriptions.

Claim Review: When an insurance provider receives a claim, a group of reviewers analyzes the claim to decide whether it falls within the insurance plan's eligibility, coverage,and liability guidelines.

COBRA: The Consolidated Omnibus Reconciliation Act (COBRA) of 1985 is a federal law that requires some employers to provide group health insurance coverage for a period of time (usually 18 months) after an employee has left the company. The former employee still receives the company's group rate but often must assume the full cost of his or her own premiums during this period.

Coinsurance: Coinsurance is the percentage of covered expenses paid by the patient each year after he/she meets his/her deductible. For example, 20 percent coinsurance means that the patient pays 20 percent of the expenses.

Coordination of Benefits (COB): If the patient is insured under more than one plan (for example, the patient and the patient's spouse have family coverage from two different employers), COB determines which plan is responsible for which services and in what sequence the coverage will apply. COB is designed to eliminate duplicate coverage in these situations.

Copayment: A flat amount the insurer may require the patient to pay for a specific service at the time the patient receives it. For example, the plan may require the patient to make a $25 copayment whenever visiting the doctor. The copayment amount varies, depending on the patient's insurance plan.

Coverage: The type and range of benefits-services, procedures, medical items, and so on-for which an insurance policy will pay. Coverage varies from payer to payer. It may include surgery or medical treatment of illnesses or injuries, emergency room care, hospital services, home health care, and medications.

Eligibility: The insurance policy criteria that a patient must meet for coverage.

Exclusion: A health care service that an insurance plan will not cover (for example, cosmetic surgery).

Explanation of Benefits (EOB): This is the information an insurance company provides a patient about a certain claim, i.e., what service were provided by whom, the amount charged for the services, what action the insurance company took, and how much the insurance company paid on the patient's behalf. This is also known as Explanation of Medical Benefits.

Fee for Service: Health service provider charges for each service rendered. Reimbursement is based upon allowable charges established by the payer.

Formulary: A specific list of drugs that an insurer approves for reimbursement. Any drugs not in this formulary list are either not covered or covered at at different benefit level.

Health Care or Health Service Provider: A doctor, hospital, home health care companies, pharmacy, or other approved supplier of health care services, equipment, prescriptions, etc.

Health Maintenance Organization (HMO): An organization that provides health care services to a specific group of people for a fixed periodic prepayment.

Home Health Care (HHC): Special provider that delivers Humatrope to your home according to your needs.

Humatrope Reimbursement Advocate (HRA): A person at HRC specifically assigned to you to assist you with reimbursement matters.

Maximum Benefit: The most an insurance carrier will pay during a specified time period.

Medicaid: This joint federal and state program provides health care coverage to low-income families and disabled individuals, plus long-term care to elderly individuals who meet certain income guidelines. Because each state administers Medicaid, eligibility and coverage requirements differ from state to state. This is also known as Title XIX.

Medical Case Management: This is most often used in cases of catastrophic or chronic illness. An insurance provider's medical case manager or coordinator will recommend treatment and services for individual needs.

Medicare: Run by the Centers for Medicare and Medicaid (CMS). Medicare is a federally funded program that provides health insurance to individuals who are disabled, age 65 or older, or suffering from end-stage kidney disease.

Out-of-Pocket Limit: The out-of-pocket limit is the maximum amount of covered expenses the patient and the patient's family could pay each year. After the patient has met the annual deductible, he/she generally pays a percentage of covered expenses (often 20 percent), up to the patient's out-of-pocket limit. Once the patient has reached his/her out-of-pocket limit, the plan pays 100 percent of covered expenses for the remainder of the calendar year.

Participating Provider: A provider who has contracted to provide medical services to an insurer's covered plan members. This term could include doctors, hospitals, pharmacies, home health care companies, and some other health care facilities if they have contractually accepted the terms of a specific insurance plan.

Patient Assistance Program: A service offered by pharmaceutical companies to provide assistance to those individuals and families who cannot afford the cost of medication.

Pre-existing Condition: A medical condition that is present when an insurance policy takes effect. For a certain specified time period, many insurance contracts will limit or exclude coverage of this condition.

Prior Authorization: A process confirming that a specific treatment or diagnosis will be reimbursed by the insurer prior to treatment. This is also known as preauthorization or precertification.

Reauthorization: The process by which an insurance company decides if they will continue to provide insurance coverage for a certain period of time. This process generally involves review of a patient’s medical history and current medical condition. Prior insurance coverage is no guarantee that a reauthorization for future coverage will be approved.

Reimbursement: Insurance coverage for medical expenses that reduces a patient’s out of pocket medical costs. Types of cost and amounts reimbursed are very different across insurance companies and medical conditions.

Reimbursement Advocate: An employee of the Humatrope Reimbursement Center (HRC) that helps patients understand their insurance benefits and potential reimbursement for Humatrope, and also helps patients obtain reimbursement from their insurance company.

Self-funded or Self-insured: A type of insurance plan funded exclusively by the employer. In these cases, claims are often processed by a third-party administrator.

State Pharmacy Programs: State-funded programs that pay for the prescription needs of certain eligible patients.

Statement of Medical Necessity: Doctor's documentation of a patient's need for health care services.

Therapy Initiation and Therapy Maintenance: Programs provided by Eli Lilly and Company that offer eligible patients an opportunity to start Humatrope therapy before insurance coverage is obtained (Therapy Initiation), or continue Humatrope therapy during times when insurance coverage changes (Therapy Maintenance).

Utilization Review: Insurer's review to determine the appropriateness of a doctor's treatment. This review may be prospective (before the treatment occurs), concurrent (during the treatment), or retrospective (after the treatment is completed).

Veteran's Benefits: Health benefits administered by the Department of Veteran Affairs for individuals who have served in the military. Coverage is dependent upon recipient eligibility and medical necessity.

Verification of Coverage: The process by which an insurer confirms that a specific treatment is covered under the patient's plan. This often occurs before the treatment is provided.

Medical Terms

Bone age: An estimate of the maturity of the bones compared with those of average children.

Endocrine glands: Organs that produce and deliver hormones to the blood for use in the body.

Genes: Genes are segments of DNA, the body's blueprint for development and function. Genes are passed from parents to children.

Hormones: Substances that circulate in the blood and have an effect on cell growth, metabolism (see key term below) and reproduction in the body.

Growth hormone: The most important hormone for growth in childhood. IGF-I: Important growth factor produced primarily in the liver.

Hypopituitarism: A medical condition where the pituitary gland makes lower-than-normal levels of its hormones.

Idiopathic short stature (ISS): Short stature with no known cause. This condition is also called non-growth-hormone-deficient short stature.

Metabolism: The process cells use for making energy and growing.

Predicted adult height: An estimate of the height a child is expected to achieve after he or she finishes growing.

Short stature: Height below the normal growth curves for age and sex.

Short Stature Homeobox-containing gene (SHOX) deficency: A medical condition resulting from a missing or altered SHOX gene.

Target height: Sex-adjusted average of parents' heights. Also called the child's "genetic height potential."

Turner Syndrome: A medical condition in females where one of the two sex chromosomes is entirely or partially missing. In females, the X chromosomes are the sex chromosomes; in males, the X and Y chromosomes are the sex chromosomes.