Pinnacle

Glossary

% out of area members

Percentage of members outside of headquartered city/state

Accolade

Advocacy/Care Navigation platform that some employers use

Aetna

National Medical network and carrier

Annual Medical Spend

Total medical claims spend per year

Anthem

National Medical network and carrier

Anthem JAA Platform

Anthem national network with blue card

 

Anthem MCS

Anthem’s California only network

Blue Card

BlueCard gives you access to the Anthem network across the nation by uniting Anthem’s network with those of other Blue Cross and Blue Shield licensed companies

Blue Shield

National Medical network and carrier

 

Carrier

A BUCA carrier (Blue Cross & Blue Shield, UnitedHealth Group, Cigna, Aetna)

 

Carrier Direct

When an employer is has direct/bundled insurance through a national carrier (i.e. Anthem, Cigna, Aetna, UHC)

CIGNA

National Medical network and carrier

Employee Advocacy/Navigation

A solution that brings all of your benefits into one place and provides high touch concierge service. (i.e. Rightway, Accolade, Quantum, HealthJoy)

Employees on Medical Plan

Number of employees enrolled in medical benefits plan that will be administered

First Health

Regional narrow network and wrap network

Fully Funded

Type of insurance funding for an employer

Funding

The way your medical plan id funded (i.e. Fully Insured or Self-Funded)

Health Management

Population management services insurance companies/TPA offer to help mitigate cost (i.e. Disease Management, Cancer Awareness, Mommies 2B, Case Management)

HealthJoy

Advocacy/Care Navigation platform that some employers use

HealthSmart

Regional narrow network and wrap network

In Area Medical Spend

Total medical spend in geographic location where employer is headquartered

 

Location

Employer's headquarters

 

Out of Area Medical Spend

Medical spend outside of geographic location of employers Headquartered city/state

Out of Network

Claims for members that go to a non-network provider (i.e. member has Anthem Network and goes to a physician/Hospital that is not contracted with Anthem)

Pharmacy Benefits Manager

Employers Prescription Drug Benefits Manager

PHCS

Regional narrow network

Primary Medical Network

The employer's primary medical network for their members (i.e. Anthem, Blue Shield, Aetna, Cigna, UHC)

 

Quantum

Advocacy/Care Navigation platform that some employers use

Reference Based Pricing

A type of arrangement where you don’t have a medical network to maximize savings.  All claims are paid at a percentage of Medicare and members can go anywhere for care.

Rightway

Advocacy/Care Navigation platform that some employers use

Self-Funded

Type of insurance funding for an employer

TPA

Third Party Administrator

 

UHC

United Healthcare - National Medical network and carrier