Health Insurance Glossary
We want you to know the ins-and-outs of health insurance. That's why we've built this glossary of terms because we know that although the words are English, they often have different meanings than what we know them to be. You can check for a specific term that you are curious about or read the entire glossary if you are prepared for the most fun-filled day you have ever had. Enjoy.A-C D-F G-K L-N O-Q R-T U-Z
Date of Service
Date of Services is the date that the medical service was performed.
A Deductible is an out-of-pocket expense that an insured person must pay for before their health insurance provider pays the costs.
Deductible Carry-Over Credit
A Deductible Carry-Over Credit is a credit applied to the next calendar year for medical expenses incurred during the last three months of the previous calendar year. These expenses may be used to meet the next year's deductible.
Dental Health Maintenance Organization (DHMO)
A Dental Health Maintenance Organization (DHMO) is a dental insurance plan that offers access to an extensive network of participating dental services. These providers have agreed to the contracted rates negotiated by the insurance company.
Dental Point of Service Option (Dental POS)
A dental plan that give the insured the option of choosing a participating provider from the DHMO network, or an out-of-network provider. The total out-of-pocket expense will usually be higher when choosing the out-of-network provider.
Department of Health and Human Services
The Department of Health and Human Services is a federal division of the U.S. government that is responsible for the Medicare and Medicaid programs.
Dependent Coverage is medical protection provided to the dependents of an insured. A dependent may be a spouse or child (age restrictions may apply).
Designated Mental Health Provider
A Designated Mental Health Provider is an organization designd to provide and treat mental health and substance abuse health services.
Diagnostic and Treatment Codes
Diagnostic and Treatment Codes are a standardized number assigned to provide a brief description of a diagnosis of the insured and the specific treatments or services that were performed by the provider. These codes are used primarily on the insurance claim forms that are submitted to insurance company for payment.
A system of coordinated health care for populations with conditions utilizing preventive, diagnostic, and therapeutic treatments. This process of reduces health care costs and or improves quality of life for individuals by preventing or minimizing the effects of a disease, usually a chronic condition, through integrative care.
Drug Formulary is a list of prescription drugs that are preferred by your health insurance provider to be dispensed through a pharmacy. Prescription drugs not on this list need to be approved by your provider.
Drug Utilization Review (DUR)
Drug Utilization Review (DUR) promotes patient safety by an increased review and awareness of outpatient prescribed drugs.
Due Process Clause
Due Process Clause is a provision in the health care providers contract that states if they are terminated that they have the right to appeal the termination with the health insurance company.
The Effective Date is the exact date that your health insurance coverage begins.
Electronic Medical Record (EMR)
Electronic Medical Record (EMR) is an individual patient's medical records in a digital format. Electronic medical records (EMR) co-ordinate, store and can retrieve a patients medical records using a computer. Electronic Medical Records are sometimes know as Electronic Health Records or Computer-Based Patient Records.
The Eligibility Date is the date that the insured becomes eligible for health insurance benefits from a health insurance provider.
Eligibility Requirements are rules imposed by health insurance companies to determine eligibility for coverage.
An Eligible Dependent is a person (spouse or child) who is eligible to receive medical coverage according to the rules outlined in a health insurance contract.
An Eligible Employee is an employee who is eligible based on the rules indicated in a group health insurance contract.
Eligible Expenses are specified expenses authorized for health service fees under a health insurance plan.
An Eligible Person is an individual allowed to received healthcare coverage without being an employee of a specified employer. This type of person may be a member of a union, association, etc.
An encounter is a visit to a health care provider by a member for services.
Enterprise Scheduling System
Enterprise Scheduling System is a system that allows physicians, hospitals and other provider facilities to function as a single group to reduce costs and increase access to facilities for insureds.
A Fee Schedule is a predetermined fee for a service that the health care provider has agreed to accept from the health insurance company. These are also known as negotiated fees, allowable fees, maximum fees.
A Fee-For-Service Plan, also called an Indemnity Plan, is a benefit payment plan in which a health insurance provider reimburses a group member directly after medical services are rendered.
Fictitious Business Name Statement
A Fictitious Business Name Statement is a business name that does not reveal the true identity of an individual owner, the partners involved or the true nature of the business. In the healthcare industry, this statement refers to a group health insurance owner.
Flexible Spending Account (FSA)
Health Flexible Spending Accounts are employer-established benefit plans. These plans may be offered in conjunction with other employer-provided benefits as part of a cafeteria plan. If you are self-employed, you are not eligible for a FSA. There may be limitations for key employees or those who have high compensation.
Formulary is a list of prescription drugs chosen by a medical institution and approved by a health insurance provider for the treatment of a patient. The drugs on this list are preferred. Outside drugs are rarely chosen.
Fully Funded Plan
In a Fully Funded Plan, a premium is paid to the health insurance company who then pays claims and administers the health insurance plan. An alternative to a Fully Funded Plan is a Self-Funded Plan.