HealthShare Terms - Crown Administrators

DRAFT – DO NOT USE

Altrua HealthShare is NOT Insurance, it is not underwritten by an Insurance company, it is a non-profit established to provide a mechanism for individuals to help share in the burden of medical costs. Because it is a voluntary membership each member remains a self-pay patient and ultimately is responsible for the cost of their medical care. The membership is voluntary and while members have agreed to share in each other’s medical needs there is no legal requirement for them to do so. Please visit the Altrua HealthShare website to view notices specific to your state, if any.

As such, you will notice that there are some terms with which you might not be familiar.

Traditional Insurance Term	vs	Altrua HealthShare Term
Claim(s) or Medical Expenses		Medical Need(s)
Deductible		First MRA
Co-Insurance		Second MRA
Contract		Agreement
Co-Pay		Office Visit MRA
Customer		Member
EOB (Explanation Of Benefits)		EOS (Explanation Of Sharing)
Coverage or Benefit		Offering
Group (Family)		Combined Membership
Health Insurance		HealthShare
In-Network Provider		Affiliated Provider
Insurance Agent		Independent Member Representative (IMR)
OOP (Out of Pocket)		MRA (Member Responsibility Amount)
Patient		Member (Contributor)
Payment / Pay		Sharing / Share
Member Payment(s)		Member Contribution(s)
Policy		Membership Guidelines
POP (Proof of Payment)		POC (Proof of Contribution)
Premium or Monthly Bill		Monthly Contribution
Primary Subscriber		HOH (Head of Household)
Requirement to Join		Statement of Standards
Statement or Invoice		Contribution Request
VOB (Verification of Benefits)		Verification of Eligible Needs

Commonly Used Acronyms

ACA: Affordable Care Act
AHS: Altrua HealthShare
DBA: Doing Business As
DOS: Date of Service
HCSM: Health Care Sharing Ministry HOH Head of Household
IMR: Independent Member Representative
MRA: Member Responsibility Amount
NPF: Needs Processing Form
POH: Peoples Oriented HealthCare (This is now known as Altrua Plus) RBP Reference Based Pricing (Medicare + 50%, this may be 25%)
SOS: Statement of Standards
UCR: Usual, Customary and Responsible

DEFINITION OF COMMONLY USED ELIGIBILITY TERMS

Current Procedural Terminology (CPT) Code: A medical code set that is used to report medical, surgical, and diagnostic procedures and services.
Date of Service (DOS): The day medical services are rendered on behalf of a member. Effective Date: The date a person’s membership begins.
Eligibility: A qualification for voluntary sharing of contributions from escrowed funds, subject to the sharing limits, Membership Guidelines, Member Eligibility Manual, and/or Membership enrollment manual.
ICD-10 Code: The standard diagnosis coding system; organized by classification. A combination of letters and numbers that translates to specific descriptions of disease, illnesses, and injuries.
Ineligible: A disqualification for voluntary sharing of contributions from escrowed funds, due to the policy set forth in the Membership Guidelines.
Medically Necessary: A service, procedure, or medication necessary to restore or maintain physical function that is provided in the most cost-effective setting consistent with the member’s condition. The fact that a provider may prescribe, administer, or recommend services or care does not make it medically necessary. This applies even if it is not listed as a membership limitation, or an ineligible need in the Membership Guidelines. To help determine medical necessity, AHS may request the member’s medical records and those records may be reviewed by a licensed medical professional.
Medical Need(s): Charges or expenses for medical services from a licensed medical professional (MD, DO, ND, Chiropractor, PT, PA, etc.) or facility due to illness, accident, or injury for a single member.
Member(s): A person(s) who qualifies to receive voluntary sharing of contributions for eligible medical needs according to the Escrow Instructions, Membership guidelines, and membership type.
Membership Guidelines: An outline for eligible medical needs in which contributions are shared in accordance with the Escrow Instructions.
Membership Limitation: A specified medical condition for which medical needs arising from or associated with the condition are ineligible. An associated condition is one that is caused directly and primarily by the medical condition that is specifically ineligible. The membership limitation will be issued during the application process and may be subject to medical record review. Membership limitations (excluding cancer) do not apply to office visits/urgent care.
Needs Processing Form (NPF): A form that is required to process medical needs for accidents, injuries or medical conditions that result in a visit to the emergency room. Members must complete and submit this form to AHS within 96 hours of discharge. The form can be found at www.altruahealthshare.org/resources. The Needs Processing Form may be requested for other medical needs and must be completed and submitted to AHS within 6 months of the need to be eligible for sharing.
Pre-Existing Condition: Any illness or accident for which a person has been diagnosed, received medical treatment, been examined, taken medication, or had symptoms for 24 months prior to the effective date.
Statement of Standards (SOS): The religious or ethical standards by which AHS members agree to live by during their membership.
SOS inquiry/violation: If a member is found to be in violation of the Statement of Standards, whether after the review of medical records or during the processing of a medical need, this can be grounds for retro-denial of membership and/or all needs from date of violation can be deemed ineligible for sharing.