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 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z What does it all mean? We know it can be very confusing to interpret all of the insurance words and terms when purchasing a health insurance plan. In order to help you navigate through all of the terminology, we are providing you with the definitions of the most commonly used insurance words and terms. This glossary is provided to you as a general guide. Please refer to your contract for a complete listing and exact definition of words and terms.
A Ancillary Services - services, other than those provided by a physician or hospital, which are related to a patient's care, such as laboratory work, x-rays and anesthesia.
B Brand-name drug - prescription drug which is marketed with a specific brand names by the company that manufactures it. The manufacturer is usually the sole source for the product. Brand-name drugs may cost individuals a higher co-pay than generic drugs.
C Case Management - a process whereby a covered person with specific health care needs is identified and a plan which efficiently uses health care resources is designed and implemented to achieve the optimum patient outcome in the most cost-effective manner. Certificate of Coverage - a document given to an insured that describes the benefits, limitations and exclusions of coverage provided by an insurance company. Claim - information a medical provider or insured submits to an insurance company to request payment for medical services provided to the insured. Coinsurance - an arrangement under which the covered person pays a fixed percentage of the cost of medical care after the deductible has been paid. For example, an insurance plan might pay 80% of the allowable charge, with the insured individual responsible for the remaining 20%, which is then referred to as the coinsurance amount. Consolidated Omnibus Budget Reconciliation Act (COBRA) - the federal law that requires employers with more than 20 employees to extend group health insurance coverage for up to 36 months after a qualifying event (e.g. termination of employment, reduction in hours, divorce). Coordination of Benefits (COB) - The anti-duplication provision to limit benefits for multiple group health insurance in a particular case to 100% of the covered charges and to designate the order in which the multiple carriers are to pay benefits. Co-payment - a cost-sharing arrangement in which an insured pays a specific charge for a specific service, such as $30 for an office visit. The insured is usually responsible for payment at the time of service is rendered. This charge may be in addition to certain coinsurance and deductible payments. Covered Person - an individual who meets eligibility requirements and for whom premium payments are paid for specific benefits of the contractual agreement.
D Dependent - a covered person who relies on another person for support or obtains health coverage through a spouse, parent or grandparent who is the covered person under a plan. Diagnosis Code - a numerical classification that describes diseases, injuries and causes of death. International Morbidity Code, Manual of the International statistical Classification of Diseases & Injuries and AMA Standard nomenclature of Diseases are different diagnosis coding methods. Diagnostic Tests - tests and procedures ordered by a physician to determine if the patient has a certain condition or disease based upon specific signs or symptoms demonstrated by the patient. Such diagnostic tools include x-rays,ultrasound, nuclear medicine, laboratory, pathology services, or tests.
E Eligible Expenses - the lower of the reasonable and customary charges or the agreed upon health services fee for health services and supplies covered under a health plan. Exclusions - specific conditions or circumstances that are not covered under the contract. Explanation of Benefits (EOB) - the statement sent to an insured by his/hers health insurance company listing services provided, amount billed, eligible expenses and payments made by the health insurance company.
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I Inpatient - service provided while the patient is admitted to the hospital for at least a 24-hour period. Insured - a person who has obtained health insurance coverage under a health insurance plan.
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O Out-of-Pocket Maximum - the total amount of claims that must be paid by a covered person (i.e. deductibles and coinsurance) as defined by the contract. Once this limit is reached, covered health services are paid at 100% for health services received during the rest of that calendar year.
P Pre-Authorization - a procedure used to review and assess the medical necessity and appropriateness of non-emergency hospital admissions and outpatient services BEFORE the services are provided. Pre-Existing Condition - a health condition or medical problem that was diagnosed or treated before enrollment in a new health plan or insurance policy.Some pre-existing conditions may be excluded from coverage. Preferred Provider Organization (PPO) - a health care delivery arrangement which offers insureds access to participating providers at reduced costs. PPOs provide insureds incentives, such as lower deductibles and co-payments, to use providers in the network. Network providers agree to negotiate fees in exchange for their preferred provider status. Primary Care Physician (PCP) - a physician who is responsible for providing,prescribing, authorizing and coordinating all medical care and treatment.
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