The following glossary includes some of the most frequently used terms in health care. This does not constitute a full list. If you have additional questions please contact our billing office or your health insurance provider for more information.
The allowed amount is the maximum amount on which payment is based for covered health care services. This is often times referred to as the eligible expense, payment allowance or the negotiated rate. Charges that exceed the allowed amount are often times charges paid by the patient (see balance billing for additional information on this).
An appeal is a request for your health insurer to review a decision or grievance again.
When a provider charges/bills you for the difference of your provider's charges and your allowed amount. A preferred provider is not allowed to balance bill you for covered services. An example of balance billing is if the provider's charge is $120 and your allowed amount is $100, then your provider may bill you for the difference.
Coinsurance is your share of the costs of a covered healthcare service. This is generally calculated as a percent of the allowed amount for the service. You the patient pay the co-insurance in addition to any deductible you may owe. For example if your health insurance plan's total allowed amount for a doctor's visit is $50 and you've met your deductible your co-insurance payment of 20% would be $10.
Conditions due to the pregnancy, labor or delivery that require medical care to prevent harm to the month or the fetus. Morning sickness and non-emergency caesarean section are not considered to be complications of pregnancy.
Co-payment is a fixed amount that you pay for a covered health care service usually at the time you receive the service. This amount varies depending on the type of service received.
Your deductible is the amount you owe for health care services your health insurance plan covers before your insurance or plan begins to pay.
Equipment and supplies ordered by a health care provider for every day or extended period of time. Coverage for Durable Medical Equipment (DME) may include: oxygen equipment, wheelchairs, crutches, or blood testing strips for diabetics.
An emergency medical condition is an illness, injury or other medical condition so serious that a typical person would seek immediate care to avoid greater harm.
Typically referred to as ambulance services.
Evaluation for an emergency medical condition or and the associated treatment to prevent the condition from getting worse.
Evaluation of an emergency medical condition and treatment to ensure that the condition does not get worse.
Services that your insurance does not pay or cover.
A complaint made by you to your health insurer.
Services that help a person keep, learn or improve skills needed for daily living. These services often include physical therapy, occupational therapy, speech therapy and other services for people with disabilities either in an inpatient or outpatient setting.
A contract between you and a health insurer that requires them to pay some or all of your health care costs in exchange for you insured paying a premium.
Health care services that one receives at home.
Services that are designed to provide persons with comfort and support in the final stages of a terminal illness. Hospice services are also designed to provide comfort and support for the patient's families as well.
Care in a hospital that requires admission as an inpatient which generally requires an overnight stay. An overnight stay for observation could be considered outpatient care.
Hospital care that typically does not require an overnight stay.
The percent you pay of the allowed amount for covered health care services to providers that are contracted with your health insurance provider or plan. Services that are in-network co-insurance typically costs less than out-of-network co-insurance.
A fixed amount you pay for covered services to providers that are contracted with your plan. Just like in-network co-insurance in-network co-payments generally cost less.
Medically necessary relates to health care services or supplies needed to prevent, diagnose or treat an illness or condition and that meet the standards of medicine.
The facilities, providers and suppliers of your health insurance provider has contract with to provide you with health care services.
A provider that is not contracted with your health insurance provider to provider services to you. Generally, you will pay more to see a non-preferred provider.
The percent you pay of the allowed amount for covered health care services who are not contracted with your health insurance provider.
A fixed amount you will pay for covered health care services from providers that are not contracted with your health insurance provider.
This is the most that you will pay during a policy period (generally annually) before your health insurance plan begins to pay 100% of the allowed amount. Note that this amount never includes your premium, balance-billed charges or health care your insurance provider does not cover.
Health care services provided by a licensed medical physician (MD or DO).
A benefit provided by your employer, union or other group to help you pay for your health care services.
A decision made by your health insurance provider that a health care service, treatment, prescription drug or durable medical equipment is medically necessary. This is sometimes referred to as prior authorization, prior approval or precertification.
A provider that is contracted with your health insurance provider to provide you services at a discounted rate. Note, participating providers, are also contracted with your health insurance plan but the discounted rate may not be as significant.
Your premium is the amount that must be paid for your health insurance or plan. This is either paid by you or your employer on a monthly, quarterly or annual basis.
Health insurance that helps pay for prescription drugs and medications.
A physician (MD or DO) that provides or coordinates a range of health care services for a patient.
A physician (MD or DO) nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who coordinates or helps a patient access health care related services.
A Physician (MD or DO), health care professional or facility that is licensed, certified or accredited as required by their respective state law.
Surgery and follow-up treatment needed to correct or improve a part of the body due to natural birth defects, accidents or injuries or other medical conditions.
Health care services that help a person improve or get back the skills required for daily living that have been either lost or impaired because of an illness or injury. Rehabilitation services may include physical, occupational, speech and psychiatric rehabilitation services in either an inpatient or outpatient setting.
Skilled nursing care consists of services from licensed nurses in your own home or a nursing home facility. Skilled care services are services from technicians and therapists in your home or in a nursing home facility.
A specialist focuses on a specific area of medicine or a group of patients to diagnose manage or treat certain symptoms and conditions. A Non-physician specialist is a provider that has more training in a specific field of medicine.
The amount paid for a medical service in a geographic area based on what providers in that specific area typically charge for the same or similar services. The UCR amount is often times used in determining the allowed amount.
Care for an illness, injury or condition that is serious enough to seek immediate care but not severe enough for an emergency room visit.