ACRONYM TERMS & GLOSSARY
Account Workbook An Excel file with about 15 tabs that serves as a comprehensive inventory of each group. It includes administrative/contact information, benefits and plan details, branding, pre-certification requirements, and reimbursement preferences. Maintained by Account Management for assigned accounts.
ACH Automated Clearing House. An electronic network that allows payments to be transferred between financial institutions.
ACO Accountable Care Organization. A group of doctors, hospitals, and other providers that coordinate care for patients. The goal is to improve outcomes, reduce duplication, and prevent errors. Payments to providers are often tied to performance and outcomes.
AEP Annual Enrollment Period. A yearly period—typically in the fall—when employees enroll in employer-sponsored health plans for the upcoming year. For Medicare Advantage plans (such as MyTruAdvantage), the AEP is set by CMS and runs from October 15 to December 7 each year.
ASO Administrative Services Organization. An entity that provides services such as health plan administration, claims processing, reinsurance, and ancillary benefit administration. Typically affiliated with a parent insurance company.
Can Do An email distribution list used to coordinate group setup, renewals, changes, terminations, and documentation updates. It is being replaced by SMAX, which will function more like a ticketing system.
CIN Clinically Integrated Network. A legal entity that organizes healthcare providers to collaborate and improve clinical outcomes. More flexible than an ACO, supporting multiple contract types. Focuses on coordinated care, quality improvement, physician leadership, and better payment models.
Clear Health An organization that provides a comprehensive healthcare pricing and payment platform.
CMS Centers for Medicare & Medicaid Services. A federal agency within the Department of Health and Human Services (HHS) that administers Medicare and Medicaid programs. Formerly known as HCFA.
COBRA Consolidated Omnibus Budget Reconciliation Act. A federal law allowing employees and dependents to continue employer-sponsored health insurance after qualifying events such as job loss, reduced hours, death, or divorce.
Community / CHNw Community Health Network, a healthcare system based in the Indianapolis area. CHNw is part owner of SIHO through the Innovative Healthcare Collaborative of Indiana (IHCI), a partnership with Deaconess Health System.
Conduent The vendor that provides and supports the Health Solutions Plus (HSP) system used by SIHO.
CPT-4 Current Procedural Terminology (4th Edition). A 5-digit numeric coding system used to identify medical procedures and services. Maintained by the American Medical Association (AMA).
CRH Columbus Regional Hospital. A hospital in Columbus, Indiana that owns one-third of SIHO.
Deaconess Deaconess Health System. Based in Evansville, Indiana, Deaconess is one of SIHO’s owners through the Innovative Healthcare Collaborative of Indiana (IHCI), a partnership with Community Health Network. IHCI owns one-third of SIHO. Deaconess is also a major TPA client, and many SIHO members receive care there.
Decen Decentralization. A system where decision-making authority in healthcare is distributed to local or lower-level entities rather than centralized at a national level. This allows providers more control over patient care decisions.
DV Data Validation. An annual process used to ensure the accuracy, completeness, and consistency of patient medical data collected in healthcare settings.
ECO Electronic Claims Operations. A team within Claims Services that reviews rejected or held electronic claims, identifies issues, and contacts providers with instructions to correct and resubmit claims.
EDI Electronic Data Interchange. The electronic exchange of healthcare information between insurers and providers. Includes processes such as enrollment, eligibility verification, claims submission, and billing.
Encore SIHO-affiliated provider networks (Encore and Encore Combined) that offer in-network pricing for providers across Indiana who are not directly contracted with SIHO.
EOB Explanation of Benefits. A document sent to members that explains how a claim was processed, including payment or denial details, and information about appeal and dispute rights.
EOP Explanation of Payments. A document sent to providers detailing processed claims, including service dates, payment or denial information, and any required provider actions or appeal steps.
ERISA Employee Retirement Income Security Act of 1974. A federal law that sets standards for most employer-sponsored health and retirement plans. It ensures protections such as transparency, fiduciary responsibility, and the right to take legal action. Government and church plans are exempt.
ESI Express Scripts Inc. A pharmacy benefits manager that provides services such as mail-order prescriptions, COVID-related resources, and other pharmacy-related support.
Exempt Employee An employee exempt from certain Fair Labor Standards Act (FLSA) protections, such as overtime pay and specific break requirements. Typically includes salaried management or highly skilled professionals.
Flow Sheet A document used to track and summarize a patient’s health information over time, helping providers monitor care and treatment progress.
Fully Insured A type of health plan where the insurance company assumes all financial risk for medical claims in exchange for monthly premiums. This differs from self-insured or TPA plans, where the employer assumes the risk.
Genesys Cloud SIHO’s cloud-based phone system that replaced traditional desk phones, allowing calls to be made and received directly through a computer.
HCFA (1500) Health Care Financing Administration Form 1500. A claim form used for professional and physician services.
HCFA (Organization) Health Care Financing Administration. A federal agency created in 1977 to oversee the Medicare program. It was renamed the Centers for Medicare & Medicaid Services (CMS) in June 2001.
HEDIS Healthcare Effectiveness Data and Information Set. A standardized set of performance measures used to evaluate and compare the quality of healthcare services.
HIPAA Health Insurance Portability and Accountability Act of 1996. A federal law designed to protect patient health information and improve the portability of health insurance. It sets standards for the security and privacy of medical records and how organizations handle personal health information.
HPMS Health Plan Management System. An online platform provided by CMS used by health plans, vendors, consultants, and pharmaceutical companies to manage enrollment and meet compliance requirements for Medicare Advantage and Part D programs.
HSP Health Solutions Plus. SIHO’s main system for managing enrollment, eligibility, claims processing, benefits configuration, provider contracts, financial functions, and internal workflows between departments.
IBQ Initial Benefits Questionnaire. A form used by Sales and Configuration teams to set up newly sold employer groups within the HSP system.
ICD-10-CM International Classification of Diseases, 10th Revision – Clinical Modification. A standardized coding system used to classify diseases and medical conditions. Maintained by the World Health Organization, with U.S. modifications developed by the CDC’s National Center for Health Statistics.
IHCI Innovative Healthcare Collaborative of Indiana. A joint venture between Deaconess Health System (Evansville) and Community Health Network (Indianapolis). IHCI owns one-third of SIHO.
In Network Also called “Par” (participating providers). Refers to healthcare providers who are contracted with SIHO or part of its network arrangements.
Inspire SIHO’s Accountable Care Organization, developed in partnership with Columbus Regional Hospital.
KFI Key From Image. The process of manually entering claim information that cannot be automatically read by scanning software (such as Smart Data Solutions). The scanned image is used as the source, and data is entered into HSP by Claims Services.
Level-Funded A hybrid health plan combining features of fully insured and self-funded plans. Employers pay a fixed monthly amount covering administrative costs, expected claims, and stop-loss coverage. If claims are lower than expected, the employer may receive a refund; if higher, stop-loss insurance covers excess costs.
LTD Long Term Disability. A plan that provides income replacement when a person is unable to work for an extended period or permanently. Typically begins after short-term disability benefits end (around 90 days or 13 weeks).
Lyric (ClaimsXten) This is a technology platform that provides pre-pay claims editing. Focus is on billing irregularities or errors.
MEDADV Medicare Advantage. Also known as Medicare Part C or "MA" plans, these are an alternative to traditional Medicare Part A and B. They are offered by private companies approved by Medicare and must offer a slate of required benefits. Plans can also offer additional benefits like dental, vision, pharmacy, and wellness benefits.
Medicare PART A/B/C/D Part A: Hospital coverage, including nursing facility and hospice care. Part B: Medical Insurance, including outpatient care, physician office visits, preventive services, and durable medical equipment. Part C: Medicare Advantage, an alternative to Medicare A and B where hospital and medical coverage are bundled and can offer additional services like prescriptions and dental/vision care. Part D: Prescription drug coverage only.
Meditrac Claims Processing System within HSP.
Member Someone enrolled in a health plan. This can be the primary member (such as an employee), or spouse/dependents. The primary member is also referred to as the "subscriber" or "sub".
Member Month / Employee Month A normalized unit for assessing a health plan's participation by employees or members. Calculated by adding up the number of employees or members for each month in the data set, then dividing by the number of months. Used to calculate PEPM and PMPM figures.
MER / MLR Medical Expense Ratio / Medical Loss Ratio. The ratio of medical expenses (cost of goods sold) to revenue. An industry standard for measuring financial performance of a health insurance product or plan.
MOOP Maximum Out of Pocket. The maximum annual dollar amount an insured member will pay in a plan year. Includes deductible, coinsurance, and copays.
MTA My Tru Advantage. SIHO's product name for its Medicare Advantage plans.
Non-Exempt Employee An employee who is not exempt from FLSA protections and work rules. Typically front-line hourly workers, including some supervisors.
NPI National Provider Identifier Number. A unique 10-digit ID assigned to healthcare providers in the U.S. to streamline billing and administrative processes.
NSA No Surprises Act. A federal law protecting consumers from unexpected medical bills, especially for emergency services and certain out-of-network care (including air ambulance).
ODAG Organization Determinations and Grievances.
- Organizational Determinations: Decisions by a health plan about authorizations or payments for services.
- Grievances: Any expression of dissatisfaction by a health plan member.
OOA Out of Area. When a member receives care outside the plan’s network service area. Payment rates may differ from in-network rates.
OON Out of Network (Non-Par). Providers not contracted with SIHO or its networks. Common examples include air ambulance, pathology, anesthesiology, radiology, and emergency medicine.
OOP Out of Pocket. The amount of money an insured member must spend for a given medical service. The amount is defined by the health plan benefit schedule in the Summary Plan Document.
PBM Pharmacy Benefits Manager. A company that provides prescription drug benefit management services, including drug formularies, negotiating drug prices, and mail-order prescription fulfillment. SIHO currently uses MedImpact; in prior years it was CVS/Caremark.
PEPM Per Employee Per Month. A normalized unit for measuring revenue, medical costs, or administrative expenses. Calculated by dividing the value of interest (revenue, medical costs, or administrative expenses) by the number of employee months for the health plan. (See Member/Employee Month.)
Perfect Claim A function in HSP that pre-screens for errors in claim preparation, such as missing required information (provider NPI, diagnosis or procedure codes, patient information, mismatched data, etc.).
PMPM Per Member Per Month. Similar to PEPM, but uses all members of a health plan (employees plus dependents) instead of just employees. PMPM is generally used more often than PEPM.
PNC PNC Bank (Pittsburgh National Corporation and Provident National Corporation). SIHO is currently working with PNC Bank to transition many banking and financial services.
QPA Qualifying Payment Amount. The rate paid to providers for services subject to the No Surprises Act. It is based on the median contracted rate for a service in the same geographic and insurance market as of January 31, 2019, adjusted for inflation using the Consumer Price Index for All Urban Consumers (CPI-U).
RBQ Renewal Benefits Questionnaire. Used by Account Management and Configuration teams to set up existing groups with renewed benefits and plan changes for the upcoming year.
Reinsurance / Stop Loss A form of insurance purchased by self-insured plans to limit financial exposure.
- Specific Stop-Loss: Covers individual high-cost cases above a set amount.
- Aggregate Stop-Loss: Covers total plan costs that exceed a preset overall limit.
Repricing The process of determining the correct payment amount for a claim.
- Billed Charges: Amount submitted by the provider.
- Allowed Amount: Amount determined based on contracts and plan benefits.
- Paid Amount: Portion paid to the provider, with the remainder being the patient’s responsibility (deductible, coinsurance, etc.). In 2024, SIHO repriced claims through over 120 provider networks.
Schneck Schneck Medical Center. A hospital in Seymour, Indiana that owns one-third of SIHO.
SDS Smart Data Solutions. A vendor and software system that converts paper claims into electronic format for processing.
Self-Funded Employer-sponsored health plans where the employer assumes the financial risk of covering medical costs. The employer funds claims directly, while a health plan or administrator handles processing and administration but does not take on risk. These plans often purchase reinsurance (stop-loss) to protect against high individual or total costs.
SIHO Southeastern Indiana Health Organization. The name of the company. The parent company is SIHO Holding, Inc.
SMAX Service Management Automation X. A software solution for IT and enterprise service management. It is used for SIHO’s IT Help Desk and is being developed to replace the email-based Can-Do process for managing group enrollment, renewal, disenrollment, and information updates.
SNF Skilled Nursing Facility. A facility that provides short-term inpatient care and rehabilitation after an injury or illness.
SOC (Audit) System and Organization Controls. An annual audit of SIHO’s operational controls conducted by an external auditor (currently FORVIS). The program is managed by the American Institute of Certified Public Accountants (AICPA). It is a voluntary program that evaluates the effectiveness of an organization’s controls. SIHO falls under SOC 1, Type 2.
SPD Summary Plan Document. A document that outlines plan terms, structure, benefits, exclusions, and definitions for employer-sponsored health plans.
STD Short Term Disability. A plan that provides income replacement when a covered individual is unable to work. Typically covers the first ~13 weeks of disability, often after a short elimination period (such as 40 hours).
Subro Subrogation. The process of determining which insurer is primarily responsible for covering medical expenses. Common in cases involving auto accidents, personal injury, or workers’ compensation. SIHO uses MultiPlan (formerly Discovery Health Partners) as its subrogation vendor.
TK Software A vendor that provides electronic claims clearinghouse services. Many providers submit claims through TK Software, which includes edits to ensure claims are properly prepared for processing.
TPA Third Party Administrator. Similar to an ASO but typically independent of any one insurance company. TPAs can work with multiple insurers to provide services such as stop-loss, dental/vision, and other ancillary benefits.
UB (04) Uniform Billing Form 04 (CMS-1450). A claim form used for hospital, institutional, and mental health services, including both inpatient and outpatient care.
UHC United Health Care. The largest health insurer in the United States. Also provides network and service solutions to other health organizations. SIHO partners with UHC to access provider networks outside Indiana.
Uniflow / Events A system within HSP that enables communication and routing of information and attachments between departments. Examples include routing claims questions from Member Services to Claims, sending adjusted claims to Finance, and forwarding enrollment updates to the Eligibility team.
W-9 Internal Revenue Service Form W-9. Used to provide taxpayer identification information to entities required to file reports with the IRS. SIHO Finance collects W-9 forms from all vendors for tax reporting purposes.
