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Accredited (Accreditation)
A "seal of approval" for health care facilities. Being accredited means that a facility 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.
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
agent.
Agent
A party who is authorized by another party, the principal, to act on the principal's behalf in contractual dealings with third parties.
Agent-Brokers
Career agents who place business with companies other than their primary companies. Also known as agents of other companies, surplus brokers, or simply brokers.
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.
Applicant
The party applying for an insurance policy.
Application
A form that must be completed by an individual or other party who is seeking insurance coverage. This form provides the insurance company with much of the information it will need to decide whether to accept or reject the risk.
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
Care Plan
A written plan for one'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
COBRA
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 you and your dependents for 18 months after you leave your job. Longer durations of continuance are available under certain circumstances. If you opt to continue coverage, you must pay the entire premium, plus a two percent administration charge.
Coinsurance
The amount you are required to pay for medical care in a fee-for-service plan or preferred provider organization (PPO) after you have met your deductible. The coinsurance rate is usually expressed as a percentage of charges. For example, if the insurance company pays 80 percent of the claim, you pay 20 percent.
Coinsurance Provision
A stipulation found in most health insurance policies that requires an insured to pay a stated percentage, in excess of the deductible, of all eligible medical expenses.
Combination Company
A life and health insurance company that sells both industrial and ordinary insurance products.
Combination Clause
A clause in a disability income contract that specifies a point at which the definition of total disability will no longer be based on an insured's inability to perform his or her "own occupation" but on the insured's inability to perform "any occupation."
Combination Dental Plan
A dental plan which contains features of both scheduled and nonscheduled plans. Typically, combination plans cover preventive and diagnostic procedures on a nonscheduled basis and other services on a scheduled basis. See also nonscheduled dental plan and scheduled dental plan.
Copayment
A cost sharing arrangement in which a person pays a specific charge for a specific medical service -- say $10 for an office visit or $5 for a prescription.
Covered Person
An individual who meets eligibility requirements and for whom premium payments are paid for specified benefits of the contractual agreement
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