Health Insurance Glossary

This is a list of health insurance related terms and definitions. Test your knowledge with a game of health insurance glossary hangman. If you think it's missing any important terminology, please let me know. Thanks for your visit. Enjoy!

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Health Insurance Terms Hangman

Terms

Accredited
A seal of approval for health care facilities. For a facility to be accredited it means that it has met certain quality standards. These standards are set by private, nationally recognized groups that check on the quality of care at health care facilities.
Accumulation Period
Timeframe within a policy period in which deductible and out-of-pocket amounts are calculated. For most health insurance policies, the accumulation period is a calendar year.
Administrative Services Only
An arrangement in which an employer hires a third party to deliver employee benefit administrative services to the employer. These services typically include health claims processing and billing. The employer bears the risk for health care expenses under this plan.
ASO
An acronym for Administrative Services Only
Admitting Physician
The doctor responsible for admitting you to a hospital or other inpatient health facility.
Admitting Privileges
The right granted to a doctor to admit patients to a particular hospital.
After Care
The care or follow-up treatment needed by a patient who has recently undergone surgery, been involved in an accident or has experienced an illness requiring hospitalization.
Agent of Record
The insurance agent recognized by a client to represent the client's interests in doing business with an insurance company.
AMA
An acronym for American Medical Association.
Ambulatory Care
All types of health services that do not require an overnight hospital stay.
Ancillary Services
Services, other than those provided by a physician or hospital, which are related to a patient's care, such as laboratory work, x-rays and anesthesia
Any Willing Provider Laws
Legislation that requires health care plans to accept into their PPO and HMO networks any provider willing to agree to the network's terms and conditions.
Appeal
Request made to a payer to reconsider a decision, such as a claim denial or denied prior authorization request.  Most appeals must be submitted in writing within a specified period.
Assignment of Benefits
When an insured person assign benefits, they sign a document allowing the hospital or doctor to collect health insurance benefits directly from the health insurance company. Otherwise, the insured person pays for the treatment and is later reimbursed by the health insurance company.
Attachment
A policy modification which changes, restricts or clarifies coverage.
Beneficiary
A person eligible for benefit under a health insurance policy.
Benefit
Amount payable by the insurance company to a claimant, assignee, or beneficiary when the insured suffers a loss.
Benefit Cap
Total dollar amount that a payer will reimburse for covered health care services during a specified period, such as one year.
Board Certified
A physician who has passed examinations given by a medical specialty group and who has, as a result, been certified as a specialist in this area of practice.
Broker
A licensed legal representative of the policyholder, who negotiates with an insurance company on behalf of a customer, but is paid a commission by the insurance company.
Capitation
Capitation represents a fixed monthly dollar amount that a Health Maintenance Organization pays to a group of health care providers who have contracted with the HMO. The amount of this fixed dollar amount depends upon the number of HMO enrollees who have chosen this group of health care providers for primary care services under the HMO plan. This fixed dollar amount does not vary with how much HMO enrollees use (or don't use) services offered by this group of HMO providers. Not all HMO utilize capitation payments.
Care Plan
A written plan for an individual's health care
Case Management
A process whereby an insured person with specific health care needs is identified and a plan which efficiently utilizes health care resources is designed and implemented to achieve the optimum patient outcome in the most cost-effective manner.
Case Manager
A nurse, doctor, or social worker who arranges all services that are needed to give proper health care to a patient or group of patients.
Catastrophic Illness
A very serious and costly health problem that could be life threatening or cause life-long disability. The cost of medical services alone for this type of serious condition could cause financial hardship.
Centers of Excellence
Hospitals that specialize in treating particular illnesses, or performing particular treatments, such as cancer or organ transplants.
Certificate of Coverage
A document given to an insured that describes the benefits, limitations and exclusions of coverage provided by an insurance company.
Claim
Form submitted to a payer by a health care provider or patient to request payment for items or services.
Clinical Practice Guidelines
Reports written by experts who have carefully studied whether a treatment works and which patients are most likely to be helped by it.
Co-insurance
Cost-sharing arrangement between an insured person and the health insurance company in which the insured person is required to pay a percentage of the cost for the health care services received. Coinsurance typically applies after satisfaction of a deductible. For example, 80% coinsurance may apply after a $500 deductible has been satisfied.
Consolidated Omnibus Budget Reconciliation Act
The Consolidated Omnibus Budget Reconciliation Act of 1985, commonly known as COBRA, requires group health plans with 20 or more employees to offer continued health coverage for employees and their dependents for 18 months after the employee leaves the job. Longer durations of continuance are available under certain circumstances. If a former employee opts to continue coverage under COBRA, the former employee must pay the entire premium, plus a 2% administration charge.
COBRA
An acronym for Consolidated Omnibus Budget Reconciliation Act.
Concurrent Review
Concurrent review involves monitoring the medical treatment and progress toward recovery, once a patient is admitted to a hospital, to assure timely delivery of services and to confirm the necessity of continued inpatient care. This monitoring is under the direction of medical professionals. Concurrent review is a component of Utilization Review.
Contract Year
The period of time from the effective date of the contract to the expiration date of the contract. A contract year is typically 12 months long, but not necessarily from January 1 through December 31.
Coordination of Benefits
A provision in the contract that applies when a person is covered under more than one health insurance plan. It requires that payment of benefits be coordinated by all plans to eliminate over-insurance or duplication of benefits.
COB
An acronym for Coordination of Benefits.
Coordinated Care
Links the treatments or services necessary to obtain an optimum level of medical care required by a patient and provided by appropriate providers. It is also another term for managed care used by federal government officials.
Co-payment
Co-payment is a predetermined fee, in addition to what health insurance covers, that an individual pays for health care services. For example, a PPO may require a $20 co-payment for normal services delivered during a physician office visit.
Co-pay
Slang; An abbreviation of the term Co-payment.
Cost Sharing
This occurs when the users of a health care plan share in the cost of medical care. Deductibles, coinsurance, and co-payments are examples of cost sharing.
Covered Benefit
A health service or item that is included in a health plan, and that is partially or fully paid by the health plan.
Covered Charges
Most insurance plans, whether they are PPOs or HMOs, do not pay for all services. Some may not pay for prescription drugs. Others may not pay for mental health care. Covered services are those medical procedures for which the insurer agrees to pay. They are listed in the policy.
Covered Expenses
See also Covered Charged.
Covered Person
An individual who meets eligibility requirements and for whom premium payments are paid for specified benefits of the contractual agreement.
Credentialing
The process used by health insurance companies to examine and verify the medical qualifications of health care providers who want to participate in the PPO or HMO network.
Creditable Coverage
Any previous health insurance coverage that can be used to shorten the pre-existing condition waiting period.
Critical Access Hospital
A small facility that gives limited outpatient and inpatient hospital services to people in rural areas.
Custodial Care
Personal care, such as bathing, cooking, and shopping.
Current Procedural Terminology
A system of terminology and coding developed by the American Medical Association that is used for describing, coding, and reporting medical services and procedures.
CPT
An acronym for Current Procedural Terminology.
Custodial Care
Personal care, such as bathing, cooking, and shopping.
Deductible
Cost-sharing arrangement between an insured person and health insurance company in which the insured person will be required to pay a fixed dollar amount of covered expenses each year before the health insurance company will reimburse for covered health care expenses. Generally, an insured person is responsible for a deductible each calendar year.
Deductible Carry Over Credit
Charges applied to the deductible for services during the last 3 months of a calendar year which may be used to satisfy the following year's deductible.
Defensive Medicine
Use of unnecessary treatments, procedures or other medical services by doctors to minimize the threat of a malpractice lawsuit.
Denial Of Claim
Refusal by a health insurance company to honor a request by an individual or his or her provider to pay for health care services obtained from a health care professional.
Dependent
A covered person who relies on another person for support or obtains health coverage through a spouse or parent who is the covered person under a health plan.
Designated Facility
A facility which has an agreement with a health insurance plan to render approved services, organ transplants being the most common example. The facility may be outside a covered person's geographic area.
Discharge Planning
Medical personnel of a health plan working with the attending physician and hospital staff to assess alternatives to hospitalization, evaluate appropriate settings for care, and arrange for the discharge of a patient, including planning for subsequent care at home or in a skilled nursing facility. The goal is to determine when patients are ready to go home, and to provide a more comfortable, cost-efficient setting for continued treatment.
Disenroll
Ending a person's health care coverage with a health plan.
Diagnostic Related Group
A Medicare-developed health care cost schedule in which medical service providers are assigned a uniform payment for specific services.
DRG
An acronym for Diagnostic Related Group.
Effective Date
The date health insurance coverage begins.
Eligible Dependent
A dependent of a covered person (spouse, child, or other dependent) who meets all requirements specified in the contract to qualify for coverage and for who premium payment is made.
Eligible Expenses
The lower of the reasonable and customary charges or the agreed upon health services fee for health services and supplies covered under a health plan.
Employee Assistance Programs
Mental health counseling services that are sometimes offered by insurance companies or employers. Typically, individuals or employers do not have to directly pay for services provided through an employee assistance program.
EAPs
An acronym for Employee Assistance Programs.
Enrollee
The person who is the primary insured. Under an individual or family policy, this person is the applicant. Under an employer-sponsored group health policy, this person is the employee.
Episode of Care
The health care services given during a certain period of time, usually during a hospital stay.
Evidence of Insurability
Proof of physical condition. This may be provided through physician records or by the results of an examination.
Exclusions and Limitations
Medical services that are either not covered or limited in benefit by a health insurance insurance policy.
Exclusion Period
A period of time when an insurance company can delay coverage of a pre-existing condition. Sometimes this is called a pre-existing condition waiting period.
Explanation of Benefits
Statement sent by health plans to persons who have experienced a claim under the health plan. The explanation of benefits details the charges for the services received, the amount the health insurance company will pay for those services, and the amount the insured person will be responsible for paying.
EOB
An acronym for Explanation of Benefits.

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