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Basic Insurance Terminology

Disclaimer: The terms listed below introduce our members to basic insurance terminology used throughout the industry. This list is in no way comprehensive, but serves as an informational tool for our members. Please review your member materials for benefit eligibility, covered services and other information pertaining to your coverage. You may also contact our Customer Care department with any additional questions.


Acupuncture: The practice of inserting thin needles to penetrate and stimulate specific points on the body to restore normal functions and energetic balance. It is considered a non-traditional treatment in Western medicine.
Adjudication: Process used by insurance companies to determine the payment amount for a claim.
Allergy Treatment: Testing and evaluations to determine the existence of an allergy, including allergy and serum injections.
Allowable Charge: The maximum fee an insurance company will reimburse a provider for a given service.
Ambulatory Surgery: Surgical procedures that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called "Outpatient Surgery."
Ambulatory Services: Services provided to a member who can walk and is not confined to a bed. Generally applies to same-day or outpatient procedures.
Appeals: Processes used by a member to request the insurance company re-consider a previous denial of authorization-- or claim decision.
Authorization: See "Preauthorization." Also known as "Precertification."


Benefit: Payments provided for covered services under the terms of the health benefit plan. The benefits may be paid to the insured, or on his/her behalf, to the medical provider.
Benefit Period: The maximum length of time for which benefits will be paid.
Brand Name Drug: A patented prescription drug available only through the manufacturer.


Case Management: A program that assists the member in determining the most appropriate and cost effective treatment plan. Case management is usually provided to members who have prolonged, expensive or chronic conditions. The program helps determine the treatment location (hospital, other institution or home).
Certification: (also known as a "Pre-Cert." or "Precertification") A health benefit plan provision requiring the member to obtain approval for a medical service, from the insurance company or HMO, before receiving the medical service.
Chemotherapy: Treatment of malignant disease (such as cancer) by chemical or biological antineoplastic agents.
Chiropractic Care: An alternative medicine therapy administered by a licensed chiropractor. The chiropractor adjusts the spine and joints to treat pain and improve general health.
Claim: A request for payment for benefits received or services rendered.
COBRA: (Consolidated Omnibus Budget Reconciliation Act of 1985) A federal law that requires employers, with 20 or more employees, to offer continued health insurance coverage to eligible employees (and their beneficiaries) whose group health insurance has been terminated under certain circumstances.
Coinsurance: An arrangement under which the member pays a fixed percentage of the cost of medical care after the deductible has been paid. For example, an insurance company might pay 80 percent of the allowable charge, with the member responsible for the remaining 20 percent; the 20 percent amount is then referred to as the coinsurance amount.
Coinsurance maximum: Total amount the member will be required to pay in a year for deductibles and coinsurance. It is a stated dollar amount, determined by the insurance company or HMO, in addition to regular premiums.
Continuation: A situation where a member who would otherwise lose health insurance coverage due to termination of employment or loss of eligibility is allowed to continue coverage, under the group's policy, for a limited period of time under specified conditions.
Contraception: Methods or devices, such as drugs, sexual practices or surgical procedures, employed to prevent conception or impregnation.
Contract: A legal agreement between an individual subscriber or an employer group, and an insurance company describing the benefits and limitations of coverage. One subscriber could have two contracts (policies) - one for health and one for dental. This document can also be called a "Certificate" or "Policy."
Contract Holder: See "Subscriber."
Conversion Option: An option provided a member to change from group medical care coverage to another form of coverage, such as individual coverage at a non-group rate. The health benefit plan defines under what conditions a conversion can be made, usually made when the member leaves the group, such as retirement.
Coordination of Benefits (COB): A mechanism allowing a member covered by more than one health plan to potentially recover up to 100 percent of the billed amount of a claim. Generally, the primary (first) plan pays the greater amount and the secondary plan pays the balance.
Copayment (or copay): The fixed amount a member pays per visit to a provider for in-network health care services. The copayment may vary per group and per service.
Covered Services: Hospital, medical and other health care services incurred by the member that are entitled to a payment of benefits under a health benefit plan.
Custodial Care: Care that is provided primarily to meet the personal needs of the member. Such care includes help in walking, bathing or dressing. It also includes preparing food or special diets, feeding, administering medicine or any other care that does not require the continuing services of medical-trained personnel.
Customary and Reasonable (C&R): See "Reasonable and Customary."


Day Treatment Center: A licensed outpatient psychiatric facility that provides outpatient care and treatment of mental or nervous disorders or substance abuse under the supervision of physicians.
Deductible: The amount of eligible expenses a member must pay each calendar year (or contract year) before the insurance company will make a payment for eligible benefits. Usually applies to the out-of-network services, but may apply to in-network services for certain products.
Dental Care: Care or services provided by an appropriately credentialed provider for the care and maintenance of the oral cavity including teeth, gum disease and oral surgery.
Dependent: Person (spouse, child or unmarried child) other than the subscriber who is covered in the subscriber's health benefit plan. Does not include aunts, uncles, mothers, fathers and grandparents regardless of their financial dependence on the subscriber. Also called a "Member" or "Beneficiary."
Diagnostic Tests: Tests and procedures ordered by a physician or other health care provider to determine if the member has a certain condition or disease based upon specific signs or symptoms. Such diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory, pathology services or tests.
Drug Formulary: A list of preferred pharmaceutical products that the insurance companies, working with pharmacists and physicians, have developed to encourage greater efficiency in the dispensing of prescription drugs without sacrificing quality.
Durable Medical Equipment (DME): Reusable, medically necessary equipment that serves a medical purpose such as maintaining functional ability. DME is not intended for personal comfort or convenience and is designed for repeated use. Some examples are: air compressor for oxygen therapy, walkers and postural drainage board. Also called "Medical Equipment."


Effective Date: The date on which the coverage of a health benefit plan goes into effect at 12:01AM.
Emergency Care: Care for members with severe or life-threatening conditions that require immediate intervention. See member's health benefit plan for detailed circumstances considered a "Medical Emergency."
Enrollee: An individual who is enrolled and eligible for coverage under a Health Benefit Plan. Also called "Member."
Exclusions: Specific conditions, services, supplies or circumstances that are not covered under the health benefit plan. It is very important to consult the health benefit plan to understand what services are not covered benefits.
Experimental Procedures: Surgical or medical treatments, procedures, drugs, or research studies that are not recognized as acceptable medical practice and any such services where federal or other governmental agency approval is required but has not been granted.
Expiration Date: The date indicated in an insurance or HMO contract as the date coverage expires.
Explanation of Benefits (EOB): An itemized receipt that lists the details of payments or denials made by an insurance company or HMO per claim. The formats of these statements vary by insurance company.


Formulary: See "Drug Formulary."


Generic Drug: A drug that is the pharmaceutical equivalent to a brand name drug. The Food and Drug Administration has approved such generic drugs as meeting the same standards of safety, purity, strength and effectiveness as the brand drug.


Health Benefit Plan: The insurance product, offered by a health insurance company or HMO, defined by the contract and represents a set of covered services and a provider network.
Health Maintenance Organization (HMO): A type of health benefit plan under which the members receive all medical services through a specific group of participating providers.
Hearing Services: Care or services provided by an appropriately-credentialed provider for the care and maintenance of the auditory senses. Does not usually include hearing aids or other devices.
HMO: See "Health Maintenance Organization."
Home Health Care: Health services rendered in the home to a member confined to the home. Such services are provided to aged, disabled, sick or convalescent members who need nursing services or therapy, medical supplies and special outpatient services, and who otherwise would need to be hospitalized.
Home Infusion Therapy: The administration of intravenous drug therapy in the home.
Hospice: A facility or Home Health Care Agency that provides care for the terminally ill member and who provides support to the family. The care, primarily for pain control and symptom relief, can be provided in the home or in an inpatient setting.
Hospital: An institution whose primary function is to provide inpatient services for a variety of medical conditions, both surgical and non-surgical. Most hospitals provide some outpatient services, particularly emergency care.


ID Card/Identification Card: A card issued to a member, which allows the member to identify himself/herself as a health plan member to a provider for health care services. The provider uses the card to determine benefit levels and to prepare the billing statement.
Indemnity: A traditional health benefit plan that reimburses for medical services provided to members based on bills submitted after the services are rendered. Also known as a fee-for-service plan. These plans generally do not have a specific provider network unless they are a preferred provider network plan (PPO).
Immunizations: A substance given to a member to create a resistance to a specific disease, also called a "vaccination." For example, a measles immunization is routinely administered to children.
In-Network: (Also known as "Partcipating") Refers to the use of providers who participate in the insurance company's provider network. Many benefit plans encourage members to use participating (in-network) providers to reduce the member's out-of-pocket expense.
Infertility: Term used to describe the inability to conceive or an inability to carry a pregnancy to a live birth after a year or more of regular sexual relations without the use of contraception. Also includes the presence of a condition recognized by a physician as the cause of infertility.
Infusion Therapy: Treatment accomplished by placing therapeutic agents into the vein, including intravenous feeding. Such therapy may also include enteral nutrition, which is the delivery of nutrients into the gastrointestinal tract by tube.
Inpatient: Service provided after the member is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.
Investigational Procedures: Surgical or medical treatments, procedures, drugs or research studies that are not recognized as acceptable medical practice and any such services where federal or other governmental agency approval is required but has not been granted.


Managed Care: Any form of Health Benefit Plan using a network of contracted providers and which may require preauthorization for certain services.
Maternity Care: Services that generally include prenatal care, normal delivery services and routine newborn nursery care.
Medical Equipment (DME): see "Durable Medical Equipment."
Medically Necessary: To evaluate services to determine if they are medically appropriate, consistent with diagnosis, cost effective, and accepted as standard care within the medical community.
Member: An individual enrolled in and covered by a health benefit plan. Also called an "Enrollee" or "Beneficiary."
Mental Health/Behavioral Health: Conditions affecting thought processes, perception, mood and behavior. Such disorders and conditions can be biologically or non-biologically based.


Network: The doctors, clinics, hospitals and other medical providers the insurance company contracts with to provide health care to its members at negotiated rates.
Network Provider: See "Participating Provider."
Non-Participating Provider: A medical provider who has not contracted with an insurance company as a participating provider. Also may be referred to as "out-of-network," "non-contracted" or "non-par."


Occupational Therapy: Treatment to restore a physically disabled person's ability to perform activities such as walking, eating, drinking, dressing, toileting and bathing.
Out-of-Network: Health care providers who have not contracted with the insurance company to provide services. HMO members are generally not covered for out-of-network services except in emergency situations. Members enrolled in preferred provider organizations (PPO) and point-of-service (POS, including HMO/POS) coverages can go out-of-network, but will pay some additional costs.
Out-of-Pocket Maximum: Refers to the maximum amount that a member will have to pay for expenses covered under the health benefit plan. The maximum is a sum of all paid deductible and copayment or coinsurance amounts. This does not include any amount that exceeds C&R (R&C or UCR) for which the member must pay.
Outpatient: A member who is receiving care at a hospital, physician's office or other health facility without being admitted overnight to the facility. The term "ambulatory" is often used to describe outpatient care.
Outpatient Surgery: Surgical procedures performed that do not require an overnight stay in the hospital or ambulatory surgery facility. Such surgery can be performed in the hospital, a surgery center or physician office. This is also referred to as "Ambulatory Surgery."


Partial Day Treatment: A program offered by appropriately licensed psychiatric facilities, which includes either a day or evening treatment program, for mental health or substance abuse. Such care is an alternative to inpatient treatment.
Participating Provider: An appropriately licensed facility or individual of health care services or supplies, that has entered into an agreement with a managed care entity to provide eligible services or supplies to a member enrolled in a health benefit plan.
PCP: See "Primary Care Physician."
Physical Therapy: Treatment involving physical movement to relieve pain, restore function and prevent disability following disease, injury, or loss of limb.
Plan Benefit Maximum: Maximum dollar amount attributed to certain benefits within a plan. For example, infertility coverage may have a benefit maximum of $10,000.
Point of Service (POS): A type of health benefit plan that allows members to go outside the provider network for care, but requires members to pay higher out-of-pocket fees when they do.
Preauthorization: A procedure used to review and assess the medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided.
Preventive Care: Basic medical services where the focus is for prevention, early detection and early treatment of conditions such as routine physical examination and immunization.
Precertification: (also known as "pre-cert.") The process of obtaining authorization, from the insurance company, for certain medical or surgical services. It involves the determination of appropriate medical care. Failure to obtain pre-certification often results in a financial penalty to either the provider or the member.
Pre-Existing Condition: An illness or injury that manifests itself in the six months before coverage under a policy starts, and for which treatment was received or recommended by a provider in the six months before coverage started. A pregnancy, which exists on the date coverage starts, is also a pre-existing condition. Complications of such a pregnancy are not considered to be pre-existing conditions and are not subject to pre-existing condition limitations.
Preferred Provider Organization (PPO): A type of health benefit plan designed to give members incentives to use health care providers designated as "preferred providers," but that also give substantial coverage for services received from other health care providers. A PPO that requires the use of a primary care physician (PCP) is sometimes referred to as a "Point of Service" (POS) plan.
Prescription: A written order or refill notice issued by a licensed medical professional for drugs that are only available through a pharmacy (retail or mail order).
Primary Care Physician (PCP): A doctor selected by the member to be the first physician contacted for any medical problem. The doctor acts as the member's regular physician and coordinates any other care the member needs, such as a visit to a specialist or hospitalization.
Prior Authorization: The process of obtaining advanced approval of coverage for a health care service or medication. Also called "preauthorization."
Prosthetic Devices: A device that replaces all or a portion of a part of the human body. These devices are necessary because a part of the body is permanently damaged, is absent or is malfunctioning.
Provider: A licensed health care facility, program, agency, physician or health professional that delivers health care services.
Provider Network: A set of providers contracted with an insurance company to provide services to members. In the case of a "fee-for-service" or non-network health plan, the provider network is, generally, all licensed providers of covered services.


Radiation Therapy: Treatment of disease by x-ray, radium, cobalt or high-energy particle sources.
Reasonable and Customary: The amount charged or the amount determined to be the reasonable charge, whichever is less, for a particular covered service in the geographical area it is performed (same as C&R and UCR).
Referral: A written recommendation by a physician for a member to receive care from a specialty physician or facility.
Respiratory Therapy: Treatment of illness or disease that is accomplished by introducing dry or moist gases into the lungs.


Second Opinion: The voluntary option or mandatory requirement to visit another physician or surgeon regarding diagnosis, course of treatment or having specific types of elective surgery performed.
Service Area: The geographic area in which an insurance company is prepared to offer health care coverage through a network of participating providers.
Skilled Nursing Facility (SNF): A licensed institution (or a distinct part of a hospital) primarily engaged in providing continuous skilled nursing care and related services to members who require medical care, nursing care or rehabilitation services. This is available only when the member would otherwise need inpatient hospitalization.
Speech Therapy: Treatment for the correction of a speech impairment that resulted from birth, disease, injury, or prior medical treatment.
Subscriber: The person responsible for payment of premiums, or whose employment is the basis for eligibility for membership in an HMO or other health insurance plan. The subscriber can enroll dependents under family coverage.
Substance Abuse/Chemical Dependency: Abuse of or addiction to drugs, which may or may not (depending on the governing state law) include abuse of or addiction to alcohol.


Utilization Management: A process measuring use of available resources, including professional staff, facilities, and services, to determine medical necessity, cost-effectiveness, and conformity to criteria for optimal use.
Utilization Review: A cost control mechanism by which the appropriateness, necessity, and quality of health care services are monitored by insurers, HMOs and employers.
Usual, Customary and Reasonable: The amount charged or the amount determined to be the reasonable charge, whichever is less, for a particular covered service in the geographical area it is performed.
Urgent Care: Services received for an unexpected illness or injury that is not life threatening but requires immediate outpatient medical care and cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering or severe pain.