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
  • Access
    Access is a patient's ability to obtain medical care through a health insurance plan. The ease of access is determined by the patient's location, transportation, affordability and medical care that is acceptable to the patient.
  • Accident
    An Accident is an unintended occurence that can include injury, illness or death. Having the proper health insurance coverage is of vital importance when the unexpected occurs.
  • Accreditation
    A process in which providers or healthcare organizations are evaluated to determine if they meet specified standards as determined by the institution providing approval. Accredited physicians and health insurance organizations must also maintain these standards to preserve the designation.
  • Accumulation Period
    The Accumulation Period is a timeframe within your health insurance policy when deductible expenses are calculated. Once you have satisfied your deductible within this period of time it is exhausted for the remainder of the calendar year.
  • Actively-At-Work
    Actively-At-Work is a term found in a group health insurance plan that requires an employee to be present on the day that the plan become effective. Otherwise, the employee is ineligible for group health insurance until they return to work.
  • Actual Charge
    The Actual Charge is the monetary amount charged to the health insurance plan by a physician or medical provider for a medical service or procedure. The Actual Charge may vary from the Allowable Charge as a result of the physician or medical provider being a member of the health insurance plan's network, and agreeing to a predetermined negotiated rate.
  • Actuary
    An Actuary is a mathematical professional who works for an insurance company and is responsible for analyzing and calculating health insurance premiums based upon specific data.
  • Acupuncture
    Acupuncture is a traditional Chinese medical technique that is used to treat a condition or disease. This alternative form of medicine is provided by professional Acupuncturists. Some health insurance plans will cover alternative treatments such as Acupuncture.
  • Acute Care
    Acute Care refers to the medical treatment administered, during a short period of time, by a hospital or nursing professional for specific injuries or illness to a patient.
  • Additional Drug Benefit List
    The Additional Drug Benefit List is a list of prescription drugs commonly prescribed by physicians for long-term and on-going patients. Also called a drug maintenance list by health insurance companies.
  • Adequacy
    Providing a sufficient number of healthcare providers to members in the health insurance network that meet their needs based on geographic location and specific types of providers availability.
  • Adjusted Community Rating (ACR)
    Adjusted Community Rating allows health insurance organizations to rate members or insured's, of a class or group based more on factors than geography and family composition. All members of each class are charged the same premium. States that participate in Adjusted Community Rating do not allow changes in the health insurance rates based on health status, and members do not have to undergo medical underwriting.
  • Administrative Services Only (ASO) Agreement
    An ASO Agreement, also known as an Administrative Services Only agreement, is a contract made by a health insurance provider or third party agreeing to provide the administrative tasks of benefits, claims and reporting for self-funded health insurance plans.
  • Administrative Supervision
    Under Administrative Supervision, the Commissioner of the state's division of insurance, or their direct appointee takes charge of the operations of the health insurance organization.
  • Admissions per 1000
    The Admissions per 1000 term is the number of hospital admissions recorded for every 1000 members of a health insurance plan.
  • Admits
    Admits are the number of admissions recorded that a hospital has, including inpatient and outpatient facilities.
  • Adverse Selection
    Adverse Selection, or antiselection, is a term used to identify those seeking health insurance who have a greater than average health risk compared to those who have a less than average likelihood of risk. As the risk gets higher, premiums from health insurance providers often get higher.
  • Age Change
    The Age Change is the date, in health insurance terms, that the person's age changes. The date is not necessarily the person's birthday, but may fall between birthdays. Health insurance providers use age changes to determine rates.
  • Age Limits
    Age Limits are set by health insurance providers who determine eligibilty for applicants who are applying or are renewing medical coverage. Age limits may also be applicable to dependent children on a parent's health insurance policy.
  • Age/Sex Factor
    The Age/Sex Factor is a measurement used in underwriting that compares age and sex as a factor of risk to calculate health insurance premiums. A high risk of a specific group based on ages and genders equals a higher risk of medical costs.
  • Agent
    An Agent is a licensed salesperson who is authorized by a health insurance provider to represent their services and negotiate, sell and service health insurance contracts to consumers in exchange for a commission.
  • Allied Health Professional
    An Allied Health Professional is a clinical healthcare professional who performs specialized duties in a healthcare setting. Examples incude medical assistants, speech pathologists and paramedics.
  • Allowable Charge
    The Allowable Charge is the maximum monetary figure that a health insurance company will reimburse for a service rendered. Physicians and medical professionals charge this amount, and the health insurance company typically pays the remaining balance.
  • Allowed Amount
    The Allowed Amount is the amount that a health insurance company is willing to pay for a medical service rendered. This amount is billed by a physician or medical professional, with the health insurance company typically paying the remaining balance.
  • Allowed Costs
    Allowed Costs are charges that are eligible to be covered based on their health insurance plan.
  • Alternative Delivery System
    An Alternative Delivery System is a form of healthcare service that is charged at a lower cost than typical fee-for-service services. ADSs could include hospice programs, acute care hospitals and in-home care.
  • Alternative Medicine
    Alternative Medicine is a form of medicine not typically practiced in the realm of conventional medicine. These forms can include the use of natural medicines, yoga, acupuncture and hypnosis. Alternative medicines are usually not eligible for health insurance coverage.
  • Ambulatory Care
    Ambulatory Care is a form of health service that does not require a hospital stay. Forms of this care include rehabilitation, diagnosis, treatment and sometimes surgery.
  • Ambulatory Setting
    An Ambulatory Setting is the location of a medical institution which provides health care in the form of Ambulatory Care.
  • Ancillary Fee
    An Ancillary Fee is a term used to describe a fee that exceeds the health insurance plan's allowed cost. Those fees can include services such as lab work and X-rays.
  • Ancillary Products
    Ancillary Products are additional professional health insurance services, such as oral and eye health, which can be added to existing health insurance policies for additional fees.
  • Ancillary Services
    Ancillary Services are professional medical services provided in additional to traditional medical care. Physical Therapy, Laboratory and X-Rays are examples.
  • Annual Benefit Amount
    Annual Benefit Amount is the dollar amount that a health insurance company determines is the maximum that they will pay out for medical expenses incurred by the member or insured within one year.
  • Appeals Review Committee
    When members have a dispute regarding the management of their health insurance benefits, or determination of coverage, they file an appeal with the Appeals Review Committee on the health insurance company.
  • Application Fee
    The Application Fee is a one-time fee paid to a health insurance provider for the submssion of an application for coverage. In some instances, if the application is denied, this fee may be refunded.
  • Approved Charge
    The Approved Charge Amount is the maximum fee allowed for services rendered by a physician or medical professional. The remaining balance is typically paid by the health insurance provider.
  • Approved Health Care Facility or Program
    An Approved Health Care Facility or Program is a certified facility or program aproved by a health insurance provider for individuals covered under a health insurance plan.
  • Assignment of Benefits
    The Assignment of Benefits is a method used by individual health insurance recipients in which they assign payment of medical services to a hospital or physician.
  • Attending Physician Statement (APS)
    An Attending Physician Statement is a detailed report written by a physician assessing the health status of an individual. This statement is often issued at the request of a health insurance provider to determine eligibility for medical coverage and premium rate.
  • Authorization
    Authorization is the health insurance companies policy for approving benefits and eligibility of an insured for medical treatment or procedures. Many times the healthcare provider or facility will contact the health insurance company prior to rendering service to verify health insurance coverage is in effect and the member is eligible to receive benefits.
  • Autonomy
    Autonomy is freedom of the insured to make decisions about their health care plan and their lives. Health care providers and health insurance companies must respect the right of the insured to make these decisions.
  • Balance Billing
    Balance Billing occurs when an out-of-network physician is used for a medical services. The individual with the health insurance plan is billed the difference between the medical professional's fee and the amount reimbursed under their health insurance plan.
  • Basic Hospital Expense Insurance
    Basic Hospital Expense Insurance is a type of hospital coverage that reimburses a policyowner for expenses occurred while confined in the hospital. These expenses include room and board and other miscellaneous fees.
  • Bed Days/1000
    Bed Days/1000 refers to the number of inpatient hospital days members of a health insurance plan are treated for every 1000 members insured.
  • Behavioral Health Care
    Behavioral Health Care is the coverage for services for mental health and chemical dependency.
  • Benefit
    A Benefit is the amount payable by a health insurance company after a doctor's visit or prescription drug purchase that is covered under a health insurance provider.
  • Benefit Level
    A Benefit Level is the maximum amount a health insurance company will pay for a particular service as outlined in a person's health insurance plan.
  • Benefit Package
    A Benefit Package is a description of benefits offered by a health insurance provider for a specific health insurance plan.
  • Benefit Riders
    Benefit Riders are add-ons to an existing health insurance policy that provide addiitonal coverage in other areas, such as dental or vision care.
  • Benefit Year
    The Benefit Year is a period of time, usually a 12-month period, in which a health insurance plan operates. During this annual cycle, health insurance plan features such as premiums, benefits, deductibles and benefit limits may change.
  • Binding Receipt
    A Binding Receipt is a term used to describe a guarantee of health insurance coverage, upon approval, if a premium is attached to an application for coverage.
  • Birthday Rule
    The Birthday Rule is a method of determination used by health insurance companies to decide which parent will become their dependent child's primary medical coverage.
  • Board Certified
    Board Certified refers to a physician or medical professional who has taken and passed a medical examination administrered by a professional medical board in that specialty area.
  • Broker
    A Broker is an invidual who is licensed and authorized to represent a health insurance company to solicit health insurance contracts in exchange for a commission.
  • Business License
    A Business License is a legal authorization issued by a governmental agency granting permission for a business to operate.
  • Business Structure
    A Business Structure is an organized design for establishing a type of business. Common forms of businesses include a corporation, sole proprietorship and partnership. A business structure takes into consideration all aspects of legalities including taxation, liabilities and requirements. Health insurance agents typically establish a business structure prior to engaging in operations.
  • Capitation
    Capitation is a specified compensation paid to a physician or healthcare provider in return for healthcare services for the individual with health insurace.
  • Carrier
    A Carrier is any commercial legally authorized health insurance company offering a health insurance or managed healthcare plan.
  • Carry-Over Provision
    A Carry-Over Provision allows an insured individual medical expenses from the last three months of a calendar year to be carried over into the new calendar year's deductible.
  • Case Management
    Case Management is a system used by a physician or other medical professionals to ensure appropriate healthcare is given to a patient. This process is supervised by a case manager who outlines a long-term plan and makes sure that no additional medical expenses are billed.
  • Centers for Medicare and Medicaid Services
    The Centers for Medicare and Medicaid Services is a federal agency within the U.S. Department of Health and Human Services that works with state governments to administer Medicare and Medicaid services. Previously known as the Health Care Financing Administration.
  • Certificate of Authority (COA)
    The Certificate of Authority is the license that a the division of insurance in a state issues to an insurance company or health care organization which allows it to conduct business within that state.
  • Certificate of Coverage
    A Certificate of Coverage is a detailed plan description outlining health benefits to a subscriber and their dependents. This document also states medical services that are not included.
  • Chemical Dependency Inpatient
    A Chemical Dependency Inpatient is an inpatient service for patients who are chemically dependent on alcohol or drugs.
  • Chiropractic
    Chiropractic care is a medical approach specializing in the diagnosis and treatment of the musculoskeletal system of a patient.
  • Chronic
    A Chronic condition is a medical condition that extends and persists for a long period of time for a patient.
  • Claim
    A Claim is an itemized request for medical services received. These items are submitted to a health insurance provider for payment.
  • Claim Form
    Claim Forms are used by insured's and providers to request payment for medical services rendered under a health insurance plan. Diagnostic and treatment codes are used on the forms to describe the diagnosis of the insured and the services rendered.
  • Claimant
    The claimant is the person or entity that files the claim for payment for healthcare services rendered.
  • Claims Administration
    Claims Administration is the process of determining eligibility for benefits under and insured's health insurance plan, making adjustments based on negotiated rates, and submitting payment to the health care providers.
  • Claims Examiners
    Claims Examiners, also known as claims analysts, who work for the health insurance company review all the information pertinent to the insured's claim and make a determination of benefits.
  • Claims Investigation
    Claims Investigation is the process of obtaining all of the pertinent information to the claim to determine the amount of benefits to pay to the health care provider.
  • Clinical Integration
    Clinical Integration facilitates the coordination of patient care across conditions, providers, setting and time in order to achieve the best level of health care.
  • Clinical Practice Guidelines
    Clinical Practice Guidelines outline procedures to assist providers in making decisions about a patients treatment options for specific conditions.
  • Closed Access
    A health insurance plan that has Closed Access stipulates that the insured must first see their primary care provider for services before being referred to additional network providers.
  • Closed Formulary
    In a Closed Formulary only the prescription medications on a preferred list will be covered by the health insurance plan.
  • Closed Physician Hospital Organization (PHO)
    A Physician Hospital Organization (PHO) that limits the number of health care specialists by their type of specialty.
  • Closed Plans
    Closed Plans require that the insureds use participating providers in the insurance companies network.
  • Closed-Panel HMO
    All of the providers in a Closed-Panel HMO are either direct employees of the HMO, or are members of a group that is contracted with the HMO.
  • Co-Payment
    A co-payment is a pre-determined dollar amount that an insured person must pay as part of the total amount to be paid for a medical service. That medical service may be from to a physician's office or from the purchase of a prescription drug.
  • COB (Coordination of Benefits)
    The Coordination of Benefits is a written provision used to prevent overpayment of benefits for individuals who have multiple health insurance plans. This statement helps determine the primary health insurance provider when claims are received.
  • COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985)
    The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 is a law that allows employees and their dependents an opportunity to temporarily extend their health insurance coverage after a voluntary or involuntary job loss. COBRA requires group health insurance plans sponsored by employers of 20 or more employees to be offered as an option. Coverage for qualified participants is usually offered for up to 18 months.
  • Coinsurance
    Coinsurance is the monetary percentage charged to a patient for medical services rendered after the deductibles and co-payments are met.
  • Company
    A Company is a health insurance provider offering medical services to an individual and their dependents.
  • Consolidated Medical Group
    One individual medical practice comprised of many providers who where previously independent health care providers. These groups can be comprised of providers from a single specialty, or multiple specialties making it a convenient environment for the patient to receive health care.
  • Credentialing
    The process a health care provider or health care organization must complete with the health insurance carrier to verify their competency and the status of their licenses. Each health insurance plan has a criteria which the providers must meet to ensure they are in good standing and able to provide care for the members.
• D-F
  • Date of Service
    Date of Services is the date that the medical service was performed.
  • Deductible
    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
    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.
  • Disease Management
    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
    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 Maintenance List
    A Drug Maintenance List is a catalog of prescription drugs given to long-term care patients. This list may be modified depending upon the patient's care.
  • Drug Utilization Review (DUR)
    A Drug Utilization Review is an evaluation of the use of prescription drugs and their effectiveness for patients utilizing them.
  • 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.
  • Durable Medical Equipment (DME)
    Durable Medical Equipment is a type of medical equipment that an inpatient or outpatient individual may use for medical treament. Examples include hospital beds, oxygen tanks, wheelchairs, crutches, etc.
  • Effective Date
    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.
  • Eligibility Date
    The Eligibility Date is the date that the insured becomes eligible for health insurance benefits from a health insurance provider.
  • Eligibility Requirements
    Eligibility Requirements are rules imposed by health insurance companies to determine eligibility for coverage.
  • Eligible Dependent
    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.
  • Eligible Employee
    An Eligible Employee is an employee who is eligible based on the rules indicated in a group health insurance contract.
  • Eligible Expenses
    Eligible Expenses are specified expenses authorized for health service fees under a health insurance plan.
  • Eligible Person
    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.
  • Emergency Room
    The Emergency Room is a pre-determined location for medical emergencies in which an individual's health is in serious danger and immediate medical attention is needed.
  • Employee Certificate of Insurance
    An Employee Certificate of Insurance is the evidence of an employee's enrollment and participation in a group health insurance policy. This document lists a summary of the employee's insurance plan benefits.
  • Employee Contribution
    An Employee Contribution is the employee's portion of payment for health insurance premium costs within a health insurance plan. The employee's share of the premium costs
  • Employer Contribution
    The Employer Contribution is the amount contributed toward the premium costs of an employer's health insurance contract.
  • Employer Wage and Tax Statement
    The Employer Wage and Tax Statement is a tax reporting document provided to the applicable federal agency to report the employer's tax liabilities.
  • Encounter
    An encounter is a visit to a health care provider by a member for services.
  • Enrollee
    An Enrollee is a person who is eligible for medical coverage.
  • Enrollment
    Enrollment is the total number of individuals (enrollees) in a health insurance plan.
  • Enrollment Period
    The Enrollment Period is the period of time that an individual has to sign up for a health insurance plan.
  • 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.
  • ERISA (Employment Retiree Income Security Act of 1974)
    Employee Retirement Income Security Act (ERISA) is a federal law that outlines the legal rights of those who manage their own retirement plan. These individuals include retirees who use their pension plan or those who This law states that those individuals must follow certain rules of conduct and disclose participants.
  • Estimated Cost
    The Estimated Cost is the approximate cost for health insurance benefits.
  • Evidence of Coverage
    An Evidence of Coverage is a statement of health insurance coverage and benefits for the insured member.
  • Evidence of Insurability
    Evidence of Insurability is a statement used in underwriting needed to prove an applicant's physical condition and current status.
  • Examination
    An Examination is a medical test performed by a physician for a potential health insurance applicant.
  • Exclusions
    Exclusions are special clauses in a health insurance contract that explain what conditions are not protected in a health insurance policy.
  • Exclusive Provider Organization (EPO)
    An Exclusive Provider Organization (EPO) refers to an organization where medical professionals monitor care and refer members to an in-network provider.
  • Experimental or Investigational Procedures
    Experimental or Investigational Procedures are any healthcare practices, services, devices, medicines, treatments, etc. that are not proven by science, nor accepted by medical professionals. These procedures are not covered by a health insurance policy.
  • Explanation of Benefits (EOB)
    An Explanation of Benefits is a notice explaining how a medical insurance claim will be paid. It also details the patient's responsibilities for payments.
  • Extended Coverage
    Extended Coverage is a clause in some health insurance plans that allow an insured to receive benefits for specified items after they are no longer receiving medical coverage.
  • Extension of Benefits
    An Extension of Benefits occurs when health insurance coverage falls beyond the expiration date of an insurance policy. Examples include an employee who is in the hospital and not actively at work.
  • Fee Schedule
    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.
  • Fee-For-Service Plan
    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
    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.
• G-K
  • Gatekeeper
    A Gatekeeper is another name for the primary care physician. This person is responsible for supervising and overseeing all components of a patient's medical care.
  • Generic Drug
    A Generic Drug is a substitute prescription drug manufactured by a pharmaceutical company that is typically a less expensive version. These drugs are exactly the same as a brand name drugs, but they are produced by a different company after the brand name's drug patient has expired.
  • Geographic Availability
    The Geographic Availability is the number of health care providers available within a given geographic are or to a given group on members.
  • Grace Period
    The Grace Period is a set number of days after an insured's premium coverage is due that it may not be canceled until a premium payment is received.
  • Grievance Procedure
    A Grievance Procedure is a process that allows a health plan member to voice their concerns and complaints to their health insurance provider.
  • Group
    A Group refers to the individuals medically covered under a group health insurance policy. The group members are typically the employees.
  • Group Health Insurance
    Group Health Insurance is a type of health insurance offered to employees through an organization or an employer.
  • Guaranteed Issue
    A Guaranteed Issue Plan is a term used to describe the requirement that a health insurance provider will accept everyone, regardless of age, income or health if they are approved and pay their premium.
  • Guaranteed Renewable Contract
    A Guaranteed Renewable Contract requires medical coverage for individuals as long as the person makes prompt payments to their premiums.
  • Health Care Financing Administration (HCFA)
    The Health Care Financing Administration (HCFA) is a federal agency within the Department of Health and Human Services that is responsible for the administration of the Medicare and Medicaid programs.
  • Health Care Quality Improvement Act (HCQIA)
    The Health Care Quality Improvement Act (HCQIA) of 1986 was passed by congress to protect hospitals and other health care providers who are participating in a medical peer review committees from potential liability after the revocation of a physicians hospital privileges. This act has been vital in establishing a benchmark for peer review. Since the Health Care Quality Improvement Act has been pass the National Practitioner Data Bank system has been created to report physicians whose competency has come under scrutiny.
  • Health Information Network (HIN)
    A Health Information Network (HIN) is a on-line computer network that provides a secure way to connect health care providers, insureds, and other health care professionals. This could potentially improve the coordination of care between hospitals, health care providers, medical labs and many more health care facilities. The Health Information Network also stands to lower health care costs by reducing medical errors, incomplete patient information and paper files.
  • Health Insurance Portability and Accountability Act (HIPAA)
    The Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy rule protects the privacy of individual's health information and maintains their confidentiality for patient safety. This standard of healthcare is meant to increase the efficiency and effectiveness of the healthcare system.
    Title 1 of the Health Insurance Portability and Accountability Act regulates group health insurance plans and individual health insurance plans. It can limit the restrictions that a group health insurance plan can place on its insured in regards to pre-existing conditions. It also prohibits the discrimination against employees and dependents based on their health status. Some health insurance plans may be exempt and the requirements of Title 1 and must be reviewed.
    
    Title 1 of the Health Insurance Portability and Accountability Act also protects employees when they change or lose their job by giving employees the right to buy individual health insurance when you have exhausted COBRA (Consolidated Omnibus Budget Reconciliation Act) benefits or do not have access to a group health insurance plan.
  • Health Maintenance Organization (HMO)
    A Health Maintenance Organization (HMO) is a health service that offers prepaid medical coverage for a wide range of medical services. HMO's are typically used for physician and hospital medical care not emergencies.
  • Health Reimbursement Account (HRA)
    A Health Reimbursement Account (HRA) is funded solely by the employer and may not be funded by employee salary reduction or deferrals. These employers established benefit plans can offer several benefits to the employee. The contributions made to the Health Reimbursement Account (HRA) can be excluded from the employee’s gross income, therefore reducing their tax burden. Reimbursements or distributions from the Health Reimbursement Account (HRA) may be tax free if they are to used pay for qualified medical expenses and described by the IRS Publication 502, Medical and Dental Expenses. Qualified medical expenses include amounts used to pay for health insurance premiums, amounts that are not covered under the health care plan and insurance premiums for long-term care coverage. Unused funds in the Health Reimbursement Account (HRA) can be carried forward for further reimbursement in the coming years. There is no limit on the amount that the employer may contribute on behalf of the employee. If an individual is no longer eligible for a Health Reimbursement Account (HRA), the distribution amount will added to your income and is also subject to a 10% additional tax.
  • Health Risk Assessment
    Health Risk Assessment is a statistical process in which a health insurance plan uses information about it's insureds medical history and habits to determine the probability of illness or injury.
  • Health Savings Account (HSA)
    A Health Savings Account (HSA) is a tax-free medical savings account that allows individuals to save for future medical expenses and pay for current medical fees.
  • Health Services Agreement
    A Health Services Agreement is a detailed agreement between a health insurance provider and an employer explaining all insurance benefits, standards, rules for eligibility and procedures.
  • High Deductible Health Plan (HDHP)
    A High Deductible Health Plan (HDHP) has a higher than average annual deductible and a maximum limit on annual allowable out-of-pocket expenses. These expenses include deductible or co-payment amounts but not premiums. Some High Deductible Health Plans (HDHP) may also provide preventive care without deductible. These plans may also be referred to as catastrophic healthcare plans. HDHP's are often used in conjunction with Health Savings Accounts (HSA's). Per the IRS guidelines in order to receive taxable benefits via an HSA it must be used with an underlying HDHP.
  • Home Health Agency
    A Home Health Agency is an organization that offers medical, therapeutic and other medical services to patients in their homes.
  • Home Health Care
    Home Health Care is a service performed in a patient's home for a range of medical and non-medical duties. Those services may include nursing care, cleaning, meal preparation or therapy.
  • Hospice Care
    Hospice Care refers to a specialized set of medical services performed by a team of medical professionals for terminally-ill patients and their families. These services may include grief counseling, legal help, physical therapy or spiritual care.
  • Hospital Benefits
    Hospital Benefits are benefits paid for medical expenses incurred as a result of a hospitalization stay such as room and board.
  • Hospitalists
    A Hospitalist is a physician or healthcare provider that cares for you while you are in the hospital and communicates with your primary care physician. Hospitalists are more familiar with the hospitals and their systems and procedures. These providers may also be able to spend more time with the patients as they are not trying to squeeze in hospital rounds on their lunch hour like many primary care or specialist physicians. Hospitalists may be Internal Medicine Specialists, Primary Care Physicians or Pediatricians. Hospitalists are also sometimes hired by traditional office practicing physicians to handle their on-call hours.
  • Hospitalization
    Hospitalization is the act of placing an individual in a hospital for medical treatment. The length of hospitalization depends upon the medical service.
  • Hospitalization Insurance
    Hospitalization Insurance is the full or partial medical coverage given to patients while in the hospital. Insurance may cover items such as room and board or x-rays.
  • Immunizations Programs
    Immunizations programs are preventative care programs to offer vaccines to help protect children and adults for disease or illness. There are many Immunization Programs available to help those who cannot afford to vaccinate or immunize their children or themselves. Some of these programs are available through the Center of Disease Control and Preventions (CDC).
  • In-Area Services
    In-Area Services are medical services provided in authorized locations covered within a health insurance plan.
  • Incontestable Clause
    An Incontestable Clause is an insurance policy provision that states that an insurer cannot contest a medical application after the health insurance poicy has been in force for a limited amount of time (usually two years). After that time, the contract will remain in force and the insurer cannot deny or reduce benefits that were in effect before the coverage date.
  • Indemnity Plan
    An Indemnity Plan, also called a "Fee-For-Service" Plan, occurs when an insurer pays part or all of authorized medical services that an insured selects from a health insurance provider.
  • Independent Practice Association (IPA)
    An Independent Practice Association (IPA) is a legally organized group of physicians or healthcare providers that contract with health insurance plans to provide healthcare services to the members. In an Independent Practice Association (IPA), typically the providers to share the economic risks but not the overhead.
  • Individual and Family Health Insurance
    An Individual and Family Health Insurance plan is health insurance coverage purchased by an individual (and their dependent's), not by a group health insurance plan.
  • Individual Market
    The Individual Market is the group of individuals who are not eligible for Medicare, Medicaid, or group health insurance who qualify for individual health insurance.
  • Infertility
    Infertility is the biological inability for an individual to conceive a child or contribute to the conception process.
  • Inpatient
    An Inpatient is an individual who receives medical care in a hospital for at least 24 hours.
  • Integrated Delivery System
    An Integrated Delivery System (IDS) is a provider organization comprised of medical professionals and hospitals who collaborate for a variety of medical services and treatments for the benefit of patients.
  • Intermediate Care
    Intermediate Care is a level of care that is less specialized than a planned, continuous program of nursing care.
  • IPA (Individual Practice Association)
    An Individual Practice Association (IPA) is an organization of medical physicians who are contracted with independent physicians who practice in different offices.
• L-N
  • Lab/X-Ray
    Lab's and X-Ray's are diagnostic and therapeutic ancillary services performed on patients to help analyze and treat a patient's ailments. Some X-Ray services include MRI's, Ultrasounds, CT Scans, while Lab tests may encompass blood panels and urinalysis. X-Rays from dentist visits are typically covered by standard health insurance.
  • Lapse
    A Lapse refers to the temporary loss of health insurance coverage due to unpaid premiums.
  • Length of Stay (LoS)
    A Length of Stay is the total number of days a patient remains in a medical facility such as a hospital.
  • Lifetime Maximum
    Lifetime Maximum is the maximum dollar amount a health insurance company will pay on behalf of a member during the course of their lifetime.
  • Lifetime Maximum Amount
    Lifetime Maximum Amount is the dollar amount that a health insurance company determines is the maximum amount that they will pay out for medical expenses incurred within the lifetime of the insured or member.
  • Limitations
    Limitations are the maximums amount a non-network medical physician is allowed to bill for a specific medical service.
  • Long-Term Care
    Long-Term Care is a medical service that is available to individuals with chronic or disabling diseases or conditions. Some health insurance company's cover all long-term care costs.
  • Mail-Order Pharmacy Programs
    Mail Order Pharmacy Programs offer prescription drugs that are ordered and delivered through the mail to reduce costs. Pharmacies do not have to pay for high priced retail locations and can process orders less expensively and accurately to meet the patients needs.
  • Major Medical Insurance
    Major Medical Insurance is a type of health insurance that provides medical benefits for a range or medical services subject to a large deductible. There may be limits to charges like room and board.
  • Managed Behavioral Health Organization (MBHO)
    Managed Behavioral Health Organizations (MBHO) provide behavioral health care services to insureds though an organized delivery system and implementing managed care techniques. These organizations have processes to monitor, evaluate, and increase quality and safety provided to patients.
  • Managed Care
    Managed Care is a medical delivery system that offers low-cost, high-quality medical services to individuals.
  • Managed Indemnity Plans
    Managed Indemnity Plans are similar to traditional Indemnity plans but may require precertification, or prior authorization for certain services and procedures. Members have access to any provider they choose, then pay their predetermined deductible and co-insurance and then are reimbursed for the remaining medical expenses.
  • Management Services Organization (MSO)
    A Management Services Organization (MSO) is an organization that is owned by a hospital, physician group, or a group of investors that manage and offer administrative support to individual providers or small group practices. Some Management Services Organizations (MSO) provide these services for a designated fee, while others purchase buildings, equipment and supplies and then lease them back to the providers for a fee.
  • Maternity (Inpatient)
    Inpatient Maternity refers to the medical costs associated with the birth of a child and hospitalization stay. These costs also include physician fees.
  • Maternity (Outpatient)
    Outpatient Maternity refers to medical services received outside of a hospital for the care and treatment of a woman's pregnancy. Treatment is supervised and monitored by an OB/GYN.
  • Maternity Coverage
    Maternity Coverage refers to the time that a woman stays in the hospital following the birth of a child. This medical coverage refers to inpatient and outpatient care.
  • Max Duration
    Max Duration is a short-term health insurance policy that ends after a short duration of time.
  • Maximum Allowable
    The Maximum Allowable is a limited amount of money that a health insurance provider will pay for benefits in a specified amount of time.
  • Maximum Out-of-Pocket Costs
    The Maximum Out-of-Pocket Costs are the most costs an insured person will pay for out-of-pocket medical expenses . Those expenses may include copayments, coinsurance, deductibles, etc.
  • Medicaid
    Medicaid is a federal medical program available to low-income and disabled individuals for certain medical and hospital expenses.
  • Medical Advisory Committee
    A Medical Advisory Committee for a health insurance plan reviews policies, provider contracts, compensation, changes in procedures and medical policies then makes suggestions based on their review.
  • Medical Director
    A Medical Director is a physician who provides leadership and oversight on the quality of care given to patients by a group of physicians or practice.
  • Medical Savings Account (MSA)
    A Medical Savings Account (MSA) is a savings account where tax-deferred deposits are made toward medical expenses. Also known as a Health Savings Account (HSA).
  • Medical Underwriting
    Medical Underwriting is the process of using a patients passed medical history and that of their family members to make a determination to offer coverage. This process allows the health insurance company decide who to offer coverage to, who to deny and if there should be additional charges or exclusions. Medical Underwriting helps health insurance companies avoid adverse selection.
  • Medically Appropriate Services
    Medically Appropriate Services are diagnostic or treatment procedures in which the benefits out way the risks.
  • Medically Necessary Services
    Medically Necessary Services are diagnostic or treatment of an illness or injury, disease or symptom that may be justified as reasonable and necessary to meet the generally accepted standards of medical care. These services must also be appropriate in type, frequency, duration and be considered effective for the patients illness, injury or disease. These services are not solely for the convenience of the patient or provider and are not more costly than other reasonable alternatives of treatment.
  • Medicare
    Medicare is a federal medical insurance plan that covers certain medical expenses for people 65 and older. This govern-run program may also be available to those younger than 65.
  • Medicare Beneficiary
    A Medicare Beneficiary is any individual entitled to receive Medicare benefits based on their qualification.
  • Medicare Supplement Insurance
    Medicare Supplement Insurance is a policy that pays a portion of the medical services not covered by Medicare.
  • Member
    A Member is a participant in enrolled in a health insurance plan.
  • Mental Health Inpatient
    A Medical Health Inpatient is a hospitalized individual who is receiving medical attention for mental health services.
  • Mental Health Office Visits
    Mental Health Office Visits are patient visits needed for the diagnosis and treament of mental health illnesses.
  • Messenger Model
    The Messenger Model was outlined in the 1996 Department of Justice/Federal Trade Commission Statements of Antitrust Enforcement Policy in Health Care. The Messenger Model allows independent providers to market themselves as a network. The messenger can then manage the process of negotiating fees of the individual providers with the health insurance plans, and allows the providers to market themselves as a network.
  • National Association of Insurance Commissioners (NAIC)
    The NAIC is an organization of insurance entities formed to regulator health insurance.
  • National Drug Code
    An NDC is a classification system used to identify prescription drugs. These codes are similar to the universal product code (UPC).
  • Network
    The Network is a group of doctors, hospitals, pharmacies and other medical experts hired by a health insurance provider to offer medical care to its participants.
  • Network Provider
    A Network Provider is a contract medical professional who agrees to provide a level of medical care to patients. This agrement is with a health insurance provider.
  • Non-Duplication of Benefits
    Non-Duplication of Benefits is a provision made by some health insurance provider stateing that benefits reimbursed by others will not be paid for.
  • Nursing Home
    A Nursing Home is a specialized facility licensed by and approved by a state for skilled nursing care. Care may include rehabilitation or restorative services.
• O-Q
  • Office Visit
    An Office Visit refers to medical service provided by a physician in their office.
  • Open Access
    An Open Access plan is a managed care health insurance plan that allows members to choose any provider without first visiting a primary care provider (PCP) and offers some level of benefit. The highest level of benefits occur when the member chooses a Primary Care Physician in the network and co-ordinates healthcare under the primary care physician using referrals. Reduced benefits occur when the member visits and out-of network provider. Benefits are generally paid at 80% of usual and customary charges but may vary by health insurance plan.
  • Open Enrollment Period
    An Open Enrollment Period is a length of time an individual may enroll in a group health insurance plann. This period of time typically does not require evidence of insurability.
  • Open Formulary
    In an Open Formulary, a reasonably unrestricted list of prescription drug options are available through the health insurance plan.
  • Out-of-Network Care
    Out-of-Network Care is a term that refers to physicians, hospitals or other medical providers who are not participants in a health insurance plan. Depending upon the type of plan, these groups many not be covered by insurance.
  • Out-of-Pocket Costs
    An Out-of-Pocket cost is the share a member must pay for items like coinsurance, co-payment, deductible, etc.
  • Out-of-Pocket Maximum
    The Out-of-Pocket Maximum is the predetermined limit that a person has to pay before a health insurance company will pay. .
  • Outpatient
    An Outpatient is a patient who receives medical services that do not require an overnight stay.
  • Outpatient Surgery
    Outpatient Surgery is a type of medical procedure that does not require hospitalization.
  • Over-The-Counter (OTC) Drugs
    OTC Drugs are those that do not requird a prescription.
  • Part-Time Employee
    A Part-Time Employee is any person who works less than a full-time schedule and may receive certain health insurance benefits. The work hours are typically less than 30 hours a week.
  • Partial Disability
    A Partially Disabled person is an individual who, as a result of a sickness or injury, cannot perform all duties assigned.
  • Partial Hospitalization Services
    Partial Hospitalization Services refers to a program operated by a hospital for the treatment of mental health or substance abuse.
  • Participating Provider
    A Participating Provider is a medical services provider who has a contractual agreement with another medical contractor such as a PPO or HMO.
  • Peer Review
    A Peer Review is a review of healthcare services of a physician by a panel of medical professionals equal to the servicing ability of that professional.
  • Periodic Health Exam
    A Periodic Health Exam is an evaluation of a patient's health status for preventive purposes.
  • Periodic OB-GYN Exam
    A Periodic OB-GYN Exam is a routine exam performed by an OB-GYN for preventative healthcare.
  • Physical Therapy
    Physical Therapy are duties performed by a medical professional for the treatment of rehabilitation. Duties may include assisting patients in walking and exercising.
  • Physician Hospital Organization (PHO)
    A Physician-Hospital Organization is a group of providers and hospitals joined to share in the financial risk of managed care risk contracts.
  • Place of Service
    A Place of Service is the designated location that the actual medical service is being performed.
  • Plan Name
    The Plan Name is the actual name of a person's health insurance plan.
  • Plan Type
    Plan Type is the exact type of plan offered by a person's health insurance company.
  • Point-of-Service (POS)
    A Point of Service is a type of manage care health insurance plan that allows the member to use a provider who is within the preferred provider network or to visit an out of network provider. The POS offers the savings of an HMO, with the flexibility of a PPO. When you enroll in a Point of Service plan, you choose a primary care physician (PCP) from the preferred provider network. The primary care physician (PCP) then makes referrals if additional diagnostic or treatment healthcare services are needed. If you choose to visit a provider outside the network, the benefits will be paid a reduced amount and you will have a higher co-insurance amount.
  • Policy Form Number
    A Policy Form Number is a special number assigned to a person's health insurance plan. This number is on file with the State Department of Insurance.
  • Policy Term
    A Policy Term is the exact length of time that is covered under a person's health insurance plan.
  • Practical Nurse
    A Practical Nurse is a licensed medical professional who provides medical care to patients who cannot perform dutires for themselves. Types of care may include walking, bathing and feeding.
  • Pre-Admission Authorization
    Pre-Admission Authorization is a review and approval process that may include confirmation of a person's benefits, services and restrictions before a hospital admits an individual for care.
  • Pre-Authorization/Pre-Certification
    Pre-Authorization is a process in which a person is screened for a particular medical care prior to getting treatment.
  • Pre-Existing Condition
    A Pre-Existing Condition is a medical condition that was present prior to a person obtaining a policy from a health insurance carrier.
  • Pre-Existing Condition Exclusion
    A Pre-Existing Condition Exclusion is a provision established by a health insurance company that may deny medical benefits to those to apply. The conditions identified are typically not covered by insurance.
  • Preferred Provider Arrangement (PPA)
    Preferred Provider Arrangements (PPA) are agreements and contracts between health insurance companies and healthcare providers, or groups of providers to provide healthcare services to members under their contract.
  • Preferred Provider Organization (PPO)
    A Preferred Provider Organization (PPO) is a managed care organization (MCO) that is comprised of providers who have contracted with an insurance company to provide healthcare services at negotiated rates to the members of the health insurance plan. Preferred Provider Organizations (PPO) offer more flexibility over an Health Maintenance Organization (HMO) by allowing for visits to out-of-network providers at a greater cost to the member. There is often a deductible for out-of-network expenses and a higher co-insurance.
  • Premium
    A Premium is a prepaid expense or series of payment made to a health insurance company by a patient for medical benefits.
  • Prescription Drug Coverage
    Prescription Drug Coverage is a form of medical insurance that offers all or part of a prescription drug purchase to be covered.
  • Prescription Medication
    Prescription Medications are drugs dispensed only by prescription and that have been approved by the FDA (Food and Drug Administration). These drugs require a doctor's prescription to obtain.
  • Preventative Care
    Preventative Care is comprehensive medical care that allows treatment for certain conditions such as immunizations or annual physical examinations.
  • Primary Care
    Primary Care is general medical care performed by a physician to a patient.
  • Primary Care Physician (PCP)
    A Primary Care Physician is a doctor who is responsible for the care of patient. This physician is typically the point of contact and monitors the patient's overall medical care.
  • Primary Coverage
    Primary Coverage is the health insurance coverage that is paid first when a person has more than one health insurance plan.
  • Prior Authorization.
    Prior-Authorization is a medical review process that is necessary before a patient can receive medical treatment.
  • Probationary Period
    The Probationary Period is a length of time that a person must wait until they are eligible for medical benefits for a medical condition. Pre-existing conditions may be excluded.
  • Provider
    A Provider is the physician, medical professional or medical facility that is providing care to a patient.
  • Provider Write-Off
    The Provider Write-Off is the balance of an actual charge and allowable charge for medical services rendered.
  • Pure Community Rating (PCR)
    Pure community Rating is a process that requires health insurance organizations to charge the same premium to all members of a community. The health insurance plan premiums cannot vary based on demographic factors such as geography, age or family composition.
  • Qualifying Event
    A Qualifying Event is an occurence that triggers a person's health insurance plan to be removed from a group health insurance plan. That event may be death, divorce or terminatio of employment.
• R-T
  • Rating Process
    The Rating Process is the process of determining premium rates for health insurance policies. This process takes into consideration factors such as age, sex, job, etc.
  • Reasonable and Customary Charges
    The Reasonable and Customary Charges are the average fees charged by a healthcare provider for a medical services rendered in a particular area.
  • Referral
    A Referral is an authorized permission by a healthcare provider or healthcare physician to allow a patient to receive specialized medical care from a medical specialist.
  • Registered Nurse (RN)
    A Registered Nurse is a licensed professional specialized in the treatment and care of nursing.
  • Renewal
    A Renewal is a continuance of healthcare coverage beyond its original policy terms plan.
  • Renewal Date
    The Renewal Date is the specific date that a health insurance policy become official.
  • Respite Care
    Respite Care is a medical benefit to members of a family who normally care for a patient. This benefit allows those primary caretakers a break from caring for the patient.
  • Rider
    A Rider is a legal document that modifies a health insurance policy. These changes may include the addition or expansion of medical services.
  • Schedule C
    Schedule C is a federal tax form that is used to report any loss or profit from a business. Health insurance companies ask for this form from businesses for group health insurance plans.
  • Schedule K-1
    A Schedule K-1 is a federal tax form used to report a beneficary's or business partners share of profit, credits and decuctions from specific trusts or partnerships. This form is typically required by health insurance companies for group health insurance.
  • Screening Programs
    Screening Programs are preventive programs designed to test for possible illness or disease when no symptoms are present. Some examples include breast examinations, prostate screening, cervical cancer screening and colon cancer screening.
  • Second Surgical Opinion
    A Second Surgical Opinion is an opinion provided by a second physician to determine whether a surgical procedure is necessary.
  • Secondary Care
    Secondary Care is a medical service provided by a physician who is not typically a primary care physician. This care is provided by a medical specialist such as a cardiologist or dermatologist.
  • Secondary Coverage
    Secondary Coverage is coverage that provides payment for medical fees not covered by a primary health insurance plan.
  • Self-Funded Health Insurance Policy
    A Self-Funded Health Insurance Policy is a health plan that is funded by an employer or other type of group health provider.
  • Service Area
    The Service Area is an area where a health insurance plan is accepted from members.
  • Short-Term Plans
    A Short-Term Health Insurance Plan is an insurance plan written for a shorter amount of time than traditional health insurance plans.
  • Skilled Nursing Care
    Skilled Nursing Care is a level of medical care that requires extensive training and skills in the profession of nursing. Care may include tube-feeding or wound treatment.
  • Specialist
    A Specialist is a health professional who is an expert in a particular medical field.
  • Standard Industrial Classification (SIC) Codes
    SIC Codes are four digit numbers assigned by the federal government to determine the primary use of a business. These numbers are used when applying for group health insurance to determine the premium for patients.
  • Standard of Care
    The Standard of Care is the diagnostic and treatment process that a provider should follow for a specific illness or clinical circumstance.
  • State Children's Health Insurance Program (SCHIP)
    The State Children's Health Insurance Program (SCHIP) provides health insurance coverage to children under the age of 18 from low income families who cannot afford health insurance. Each state operates under its own name and eligibility may vary based on state. These children may also be eligible for Medicaid benefits. For more information on the State Children's Health Insurance Program you may call 1-877-KIDS-Now for more details.
  • Subrogation
    Subrogation is the recovery of fees from medical services provided. This process is for members who are responsible for medical expenses.
  • Subscriber
    A Subscriber is the person responsible for premium payments or the person eligible for medical insurance benefits.
  • Temporary Partial Disability
    Temporary Partial Disability is a condition where a person is injured for a period of time but is able to work at a reduced capacity.
  • Temporary Total Disability
    Temporary Total Disability is a medical condition where a person is prevented from working while recovering from an injury.
  • Terminally Ill
    A Terminally Ill refers to the status of an extremely ill person likely to die within 6 months.
  • Tertiary Care
    Tertiary Care is highly specialized medical care for patients who are in danger of death or disability.
  • Third Party Administrator (TPA)
    A Third Party Administrator (TPA) is an organization that processes claims on behalf of health insurance company or self funded health plan but does not have financial responsibility in paying the benefits. Third Party Administrators (TPA) may also manage provider networks, utilization review, membership activities and flexible savings accounts.
  • Three-Tier Copayment Structure
    A Three-Tier Copayment Structure is a prescription drug benefit copayment system under which a member pays one level of copayment for generic drugs, a higher copayment amount for brand-name drugs and an even higher copayment amount for a non-formulary drug.
  • Treatment Facility
    A Treatment Facility is a residential or non-residential medical care facility authorized to provide treatment for the treatment of a mental health or substance abuse condition.
  • Triage
    Triage is a process by which patients are classified according to their medical condition. Treatment is then given to them sort by urgency.
  • Two-Tier Copayment Structure
    A Two-Tier Copayment Structure is a prescription drug benefit copayment system under which a member pays one copayment for generic drugs and a higher copayment for brand-name drugs.
• U-Z
  • Underwriting
    Underwriting is the process by which a health insurance company determines eligibility for a person who is seeking health insurance benefits. Factors such as age, sex and pre-conditions are taken into consideration.
  • Uniform Billing Code of 1992 (UB-92)
    The UB-92 is a federal directive that requires a hospital to follow a set of rules for the billing medical expenses.
  • Usual, Customary and Reasonable Charge
    Usual, Customary and Reasonable Charges are the amounts charges for specific medical services rendered by a doctor for medical treatment.
  • Utilization
    Utilization is the pattern of use for a type of service within a particular health plan or program.
  • Utilization Management/Review
    The Utilization Management and Review is an evaluation of a medical treatment by a healthcare professional. The review analyzes the need, appropriateness and cost-effectiveness of the service.
  • Vision Care Coverage
    Vision Care Coverage is a type of specialized medical coverage that is for treatment and examination of eyecare.
  • W-2
    A W-2 Form is a federal tax form issued by employers stating an employee's income and taxes paid for a specific year.
  • Waiting Period
    The Waiting Period is the length of time when a person is not covered by health insuance for a medical issue.
  • Waiver (Exclusion Endorsement)
    A Waiver is a term that refers to the abandonment of coverage for pre-existing conditions and future conditions.
  • Waiver of Premium
    A Waiver of Premium is a provision in a health insurance policy that states that the plan will continue without future premium payments.
  • Well-Baby/Well-Child Care
    Well-Baby Care are medical services given in the first year of a baby's life as preventive care treatments.
  • Well-Woman Care
    Well-Woman Care is the medical attention provided for women for preventative treatments. Services may include PAP Smears and Mammograms.