One health insurance company replaces one or more other health insurance carriers for a group client. This process allows merging and combining the experience and risk of the group.

Direct electronic transmission of insurance claims by the physician to the insurance company.

Provision in some medical expense policies in which expenses incurred during the last 3 months of a benefit period or calendar year are used to satisfy the current benefit period’s deductible and may also be used to satisfy any or all of the following benefit period’s (or next year’s) deductible.

Format used when a complete entry does not fit on one line and then drops down to the next line.

1. Medical service not included within the capitation rate as a benefit of a managed care contract and may be contracted for separately. For example, carve-out services might include vision and dental, sometimes called a single-service plan (SSP) . 2. Integrated plan of providing medical coverage to Medicare-eligible employees. See Medicare carve-out.

Insurance coverage for specific health care services available for purchase separately from the basic managed care plan. Also called single-service plan (SSP). Also see Medicare/employer supplemental insurance.

1. A particular instance of injury or disease, as a case of leukemia; sometimes used incorrectly to designate the patient with the disease. 2. Entire plan of a group insurance policyholder.

Past and current clinical information that the physician wants to know about the patient. The case history becomes part of the patient’s health record.

1. Ongoing review of cases by clinical professionals to ensure the necessity of the clinical services given and most appropriate use of services to a patient. Typically, case managers are nurses or social workers. They may operate privately or may be employed by social service agencies or public programs. 2. Process that integrates and coordinates patient care in complex and high-cost cases. Sometimes a patient is referred to as case managed. 3. Process of developing a defined health care plan for a patient for better communication and to improve quality of care and reduce costs. Case management is sometimes a “carve out.” See carve out. 4. In the Medicare program, an arrangement of services needed to give proper health care to a beneficiary; tracking of beneficiary’s use of facilities and resources. Also known as catastrophic case management, catastrophic claim management, large claim management, or medical case management.
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Case management is used to manage healthcare costs in workers compensation. The case manager works with the insured, the physician, and the employer to design the most cost-efficient treatment plan. Case managers also monitor the injured worker’s progress and keep the employer and insurance company informed about the worker’s ability to return to work.