Glossary

A health care provider or facility that is paid by a health plan to give service to plan members.

A person who is trained and licensed to give health care. Also, a place that is licensed to give health care. Doctors, nurses, and hospitals are examples of health care providers.

An organization administered by the NUCC that is responsible for maintaining the Provider Taxonomy coding scheme used in the X12 transactions. The detailed code maintenance is done in coordination with X12N/TG2/WG15.

An administrative code set that classifies health care providers by type and area of specialization. The code set will be used in certain adopted transactions. (Note: A given provider may have more than one Healthcare Provider Taxonomy Code.)

A provider who has a contract with your plan who has agreed to provide services to members of a plan. You will pay less if you see a provider in the network. In-network providers may also be called "preferred provider" or "participating provider."

A type of Medicare Advantage Plan in which you use doctors, hospitals, and providers that belong to the network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

The system that uniquely identifies a health care provider (as defined at 45 CFR 160.103) and assigns it an NPI. The system is designed with the future capability to also enumerate health plans once the Secretary has adopted a standard unique health identifier for health plans.

The name of the standard unique health identifier for health care providers that was adopted by the Secretary in January 2004.

A provider who doesn't have a contract with your plan to provide services. If your plan covers out-of-network services, you'll usually pay more to see an out-of-network provider than an in-network provider (or preferred provider). Out-of-network providers may also be called "non-preferred" or "non-participating." If your plan doesn't cover an out-of-network service, you may be responsible for arranging payment with the provider directly for the full cost of the care.

An M+CO coordinated care plan that: (a) has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan; (b) provides for reimbursement for all covered benefits regardless of whether the benefits are provided with the network of providers; and (c) is offered by an organization that is not licensed or organized under State law as an HMO. See Social Security Act Section 1852(e)(2)(D), 42 U.S.C. §139w-22(e)(2)(D).