Appeal: A process in which the provider or patient requests that a claim be reconsidered after the claim is denied
C
Catastrophic Plans: Insurance plans that only pay for treatment for catastrophic events.
Carrier: Insurance Company
Claim: A request for payment for a service or supply made to the Insurance Company.
COBRA (Consolidated Omnibus Budget Reconciliation Act): Program that provides continued coverage when they would otherwise lose eligibility such as when a patient is laid off from employment.
Contract: The agreement that exists between either the Insured and the Insurance Company OR the Provider and the Insurance Company.
Co-Payment: A set amount that the patient is responsible for paying according to the terms of their contract with the Insurance Company. These may or may not be due for testing depending on the terms of the contract. Providers are required to collect these payments according to the terms of the Providers’ contracts with Insurance Companies.
Co-Insurance: A percentage of the fee that a patient is expected to pay in accordance to the contract with the insurance company. Providers are required to collect these payments according to the terms of the Providers’ contracts with Insurance Companies.
Coverage Period: The time period in which the patient is covered by an insurance policy
D
Deductible: The amount that a patient must pay before the insurance company begins paying. This amount is determined by the insured’s contract with the insurance company.
Denial: The insurance company’s refusal to pay a claim.
E
Eligibility Benefits: Those services covered by the insurance company. These vary in accordance to the insured’s contract with the insurance company. For details regarding specific benefits, refer to the booklet provided by your insurance company.
Effective Date: The day that insurance policy begins to cover the patient
Explanation of Benefits (EOB): A statement from the Insurance Company explaining what they paid to providers and what portion of the bill that the patient is responsible for paying.
F
Formulary: A set of medications for which and insurance company will pay. This list varies from plan to plan and carrier to carrier. Please refer to your Benefits Guide for a list of drugs for your specific plan.
Guarantor: The person who assumes responsibility for another individual’s insurance contract, usually a parent of a minor child or power-of-attorney.
H
HIPAA: Health Insurance Portability and Accounting Act, a law passed in 1996 that protects the privacy of patients. This act allows insurance companies to share information regarding patients.
HMO (Healthcare Maintenance Organization): Insurance Plan that manages a patient’s care from a network of providers. The plan may or may not provide coverage for out-of-network providers.
HSA (Healthcare Savings Account): A healthcare plan that allows patients to save tax-free money to put toward medical expenses.
I
In-Network: A provider who is contracted with a carrier.
Insured: The person covered by an insurance policy.
Insurer: The Insurance Company.
L
Letter of Creditable Coverage: Proof provided by an Insurance Company that states the dates that the Insured was covered by a previous policy. This letter can be used to appeal a claim or have a pre-existing condition rider waived by a new Insurance Carrier. Also called a Certificate of Credible Coverage.
M
Medicaid: A program administered by individual states that provides healthcare coverage for qualifying patients. Plans and eligibility vary from state to state.
Medicaid Replacement: A private plan that takes the place of Medicaid plans. By signing up for the Medicaid Replacement, a patient opts out of the State Plan.
Medicare: A program administered by the Federal Government to provide healthcare coverage for qualifying patients.
Medicare Advantage Plans (Replacement): A private plan that takes the place of Medicare benefits. By signing up for a Medicare Replacement, a patient opts out of the Federal plan.
Medicare Supplement: A private plan to adds to Medicare benefits.
O
Out of Pocket Expense: The maximum amount a patient has to pay before insurance begins paying at 100%. This may or may not include co-payments, co-insurance, deductible payments, or prescription costs.
Out of Network: A provider who is not contracted with a particular carrier.
P
Participating Provider: This term refers to the entity that is accepting payment from an Insurance company. This may include Physicians, Pharmacies, Dentists, Medical Equipment Suppliers, Therapy Centers, Hospitals, and Clinics.
Plan: Terms of the contract between the Insured and the Insurer. Each carrier has multiple plans.
POS (Point of Service): A hybrid plan of the HMO and PPO services. Coverage type is decided at the time of service.
PPO (Preferred Provider Organization): A healthcare plan that offers flexibility of providers. Typically, patients can see an in-network provider for a lower cost or an out-of-network provider for a higher cost.
Pre-Certification: A process in which the Provider requests permission to proceed with a test. Pre-certification is not a guarantee of payment.
Pre-Existing Rider: A condition, such as heart disease or allergies, that a patient had prior to signing a contract with and Insurer. These conditions may disqualify a patient for coverage for this specific condition for a set amount of time. However, many Carriers will waive this if the Insured provides a Letter of Credible Coverage from his or her previous carrier.
Preventative Care: Tests that seek to detect disease before patient becomes symptomatic.
Primary Care Provider (PCP): The Provider who directs the care of the Insured.
Prior Authorization: A process in which the Provider requests that Insurance Company covers the expense of a product such as a medication that is not on the company’s formulary. This process may take up to 2 weeks.
Premium: The amount that the Insured pays to the Insurance Company.
R
Referral: Process through which one Provider requests that another Provider see a patient. Each provider has a different process for requesting an appointment. Some carriers do not require referrals from a Primary Care Provider (PCP) to a specialist, but it is best to check with your Carrier first.
Rider: An attachment to an insurance policy that places restrictions on the policy.
S
Specialist: A Provider who performs services for a specialized field such as Cardiology or Gastroenterology.
Subscriber: The person who agrees to pay the premiums for an insurance plan.
T
Termination Date: The day that the coverage for a specific plan ended.
Tiers: A ranking system that prioritizes the level at which a carrier will cover products. This usually refers to medication coverage.
U
Underwriter: A person or group that determines if a patient is eligible for coverage by a carrier.
Underwriting: The process by which a carrier decides whether or not to cover an individual
W
Waived: A statement in which a rider is dismissed. Pre-existing Condition Riders can be avoided if the Insured present a Letter of Credible Coverage from his or her previous carrier.
Write Off: The difference between what the Provider charges and what the Carrier is contracted to pay on the patient’s behalf.
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