Allowed Amount
The amount of the billed charge the insurance company considers...
Ambulatory Care
Medical care on an outpatient basis, such as hospital outpatient...
Ancillary Services
Professional services such as laboratory tests and radiology exams.
Assignment of Benefits
The patient or guardian signs the Assignment of Benefits form...
Benefit Penalty
An approach used by the insurance company to reduce payment...
Birthday Rule
The Birthday Rule is a way of determining coordination of...
Capitation
A payment methodology in which the physician is paid a...
Carve-out
Medical services that are separated from a contract and paid...
Case Management
A method by which a health plan attempts to control...
Certificate of Coverage
A Certificate of Coverage is a document that describes how...
Claim
A request for payment by a medical provider for a...
Co-insurance
A percentage the patient is responsible for on a given...
Co-payment
A per occurrence payment
Contracted Provider
A medical provider that has an agreement with a health...
Cost Containment
When the insurance company devises a way to reduce the...
Covered Expense
A medical procedure or item that is deemed payable by...
CPT Code
Current Procedural Terminology
Deductible
A set dollar amount which must be satisfied within a...
Emergency
An emergency medical condition is a medical condition manifesting itself...
Exclusions
Those items or medical services that are not covered by...
Explanation of Benefits (EOB)
A summary of the payment made by your health plan...
Fee for Service
A method of payment for medical services rendered
Fee Schedule
A list of CPT codes and dollar amounts an insurance...
Formulary
A listing of pharmaceuticals the health plan pays for.
Generic Drug
Generic drugs must meet the same FDA standards for safety...
HCFA 1500
The standard claim format used by health plans on which...
ICD-9 Codes
A standard format of identifying the illness, injury or diseases...
Ineligible Procedure
Ineligible procedures are medical procedures that are excluded from a...
Late Enrollee
A Late Enrollee is an individual who does not enroll...
Medical Necessity
A medical procedure or service must be performed only for...
Off-label Use
The prescribing of a medication for use not approved by...
Open Enrollment
If the plan has an Open Enrollment it is the...
Out of Pocket Expense
The amount the patient must pay themselves and not paid...
Participating Provider
A physician or other medical provider has agreed to accept...
PCP
Primary Care Physician
Pre-Authorization
If a physician wants to perform a surgery, order a...
Pre-Existing
A medical condition diagnosed prior to the effective date of...
Probationary Period
This is the time period that an employer or carrier...
Referral
The PCP requests that a specialist see the patient for...
Special Enrollee
A special enrollee has the opportunity to enroll in a...
Untimely Submission
A medical claim must be submitted within the time frame...
Usual, Customary & Reasonable
A reduction in the payment of benefits on a claim...
