Insurance Definitions

Get help understanding common insurance definitions.

• Allowed Amount
  The amount the insurance company pays for a service (may be less than what we have billed).
• Authorization / Pre-Authorization
  Formal approval by insurance to assist patient and provider in securing payment for healthcare services.
• Benefit Period
  When services are covered under your plan. It also defines the time when benefit maximums, deductibles and coinsurance limits build up. It has a start and end date. It is often one calendar year for health insurance plans.
  Example: You may have a plan with a benefit period of January 1 through December 31 that covers 10 physical therapy visits. The 11th or more session will not be covered.
• Charge
  Price for services rendered.
• Coinsurance
  A certain percent you must pay each benefit period after you have paid your deductible. This payment is for covered services only. You may still have to pay a copay.
  Example: Your plan might cover 80 percent of your medical bill. You will have to pay the other 20 percent. The 20 percent is the coinsurance.
• Contractual Allowance / Adjustment
  The difference between what an insurance company approves according to its contract and what the healthcare provider charges for the service.
• Copayment (Copay)
  The amount you pay to a healthcare provider at the time you receive services. You may have to pay a copay for each covered visit to your doctor, depending on your plan. Not all plans have a copay. (i.e. $20 for every visit to the doctor, while your insurance pays the rest).
• Cost
  Patient's out-of-pocket responsibility for services rendered.
• Covered Person
  Any person covered under the plan.
• Covered Service
  A healthcare provider’s service or medical supplies covered by your health plan. Benefits will be given for these services based on your plan.
• CPT Code
  Five-digit code(s) used to describe tests, surgeries, evaluations, and any other medical procedure performed by a healthcare provider on a patient.
• Deductible
  The amount you pay for your healthcare services before your health insurer pays. Deductibles are based on your benefit period (typically a year at a time).
  Example: If your plan has a $2,000 annual deductible, you will be expected to pay the first $2,000 toward your healthcare services. After you reach $2,000, your health insurer will cover the rest of the costs.
• Dependent Coverage
  Coverage for your dependents who qualify.
• Explanation of Benefits (EOB) or Explanation of Payment (EOP)
  These are documents showing a detailed listing of how your insurance company processed your claim or bill. An EOB or EOP is mailed by your insurance company directly to you.
• Established Patient
  For billing purposes, an established patient is defined as someone who has been seen by the provider/department within the last three years.
• HCPCS
  Is a collection of standardized codes that represent medical procedures, supplies, products and services.
• HMO - Health Maintenance Organization
  An HMO requires the member to choose a provider network and a Primary Care Provider (PCP) within the chosen network. An approved referral from his/her PCP must be in place for a member to see a specialist. If a referral is not in place prior to receiving non-emergent care, the HMO may not cover incurred services.
• Inpatient Services
  Services received when admitted to a hospital and a room and board charge is made.
• Insurance
  Coverage that pays for medical and surgical expenses incurred by the insured and/or eligible dependents.
• Medicare A
  Medicare Part A provides payments for inpatient hospital services, excluding those of physicians and surgeons.
• Medicare B
  Part B provides payments to physicians and surgeons, as well as for medically necessary outpatient hospital services (such as ER, laboratory, X-rays and diagnostic tests) and certain durable medical equipment and supplies.
• Medicare Advantage Plan
  Medicare Advantage plans are private health plans that have contracted with Medicare. These plans are paid fixed subsidies by Medicare to provide Medicare beneficiaries benefits. Most of these plans are managed care plans, which are plans that control both the financial and health services portion of the insurance plan.
• New Patient
  For billing purposes, a new patient is defined as someone who has not been seen by the provider/department within the last three years.
• Non-covered Charges
  Charges for services and supplies that are not covered under the health plan. Examples of non-covered charges may include things like acupuncture, weight loss surgery or marriage counseling. Consult your plan for more information.
• Observation
  Is a special service or status that allows physicians to place a patient in an acute care setting, within the hospital, for a limited amount of time (generally 24 to 48 hours) to determine the need for inpatient admission.
• Outpatient Services
  Services that do not need an overnight stay in a hospital. These services are often provided in a doctor’s office, hospital or clinic.
• OON - Out of Network
  Health care rendered to a patient outside of the health insurance company's network of preferred providers. In many cases, the health insurance company will not pay for these services. Emergency medical care is usually an exception to the OON rule.
• Out-of-Pocket Maximum
  The most money you will pay during your coverage period, includes deductibles, co-payments, co-insurance and balance-billed charges, but is in addition to your regular premiums.
• POS - Point of Service Program
  A POS has the same requirements as an HMO. However, members are given the additional option of self-referring outside of their PCP network. Members who choose to self-refer will incur a higher out of pocket cost.
• PPO - Preferred Provider Organization
  A PPO offers a network of providers. Members have the choice to access several providers but are given financial incentives (i.e., lower out-of-pocket costs) to use the preferred provider network.
• Premium
  Payments you make to your insurance provider to keep your coverage. The payments are due at certain times.
• Price
  Price of premiums, price of services.
• Primary Care
  General Internal Medicine, Family Practice and Pediatrics providers.
• Prior Authorization
  A request for payment authorization submitted in advance by a healthcare provider to the insurance plan for their approval to admit a patient, perform a procedure or provide a service. Pre-authorization / prior-authorization requirements are specific to each insurance plan. The insurance plan will determine medical necessity, appropriateness of services and level of care based upon their own guidelines.
• Referral
  An insurance pre-approval required from the patient's PCP BEFORE seeing a specialist.
• Self-refer
  An insurance member’s ability to receive specialty care services without written referral from member’s primary care provider and approval from their insurance. These services, however, may be denied or paid at a lesser benefit.
• Qualifying Life Event (to change insurance)
  A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage. Examples of qualifying life events are moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry, divorce, or have a baby) and gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder.