1
Are requests made by policyholders or healthcare providers to the insurance company for reimbursement of medical expenses. These expenses can include doctor's visits, hospital stays, prescription drugs, and other covered healthcare services.
Claims
Is the amount policyholders must pay out of pocket for covered healthcare services before the insurance company starts covering costs. It's an annual expense that resets each year.
Deductibles
Is a contract between an individual or group and an insurance company that outlines the coverage and benefits provided. It specifies the terms and conditions of the insurance arrangement.
Healthcare Plan/Policy
Is the specific time during the year when individuals can make changes to their existing health insurance plans or enroll in new ones. AEP typically applies to Medicare and employer-sponsored plans
Annual Enrollment Period (AEP)
The entity responsible for reimbursing or paying for healthcare claims. This can be an insurance company, a government program (e.g., Medicaid or Medicare), or a self-insured employer.
Payer
Describes healthcare providers or facilities that do not have contracts with an insurance company. Services obtained from out-of-network providers may result in higher costs to the policyholder.
Out of Network
Are claims submitted to the insurance company that are not processed due to errors, missing information, or other issues. Policyholders or healthcare providers need to correct and resubmit these claims
Rejected Claims
Is the maximum amount that policyholders are required to pay for covered medical expenses during a policy year. Once this limit is reached, the insurance company covers 100% of the remaining covered costs.
Out of Pocket Max (Out-of-Pocket Maximum)
Is the time when individuals can enroll in or make changes to health insurance plans offered through the Health Insurance Marketplace, created under the Affordable Care Act. OEP for the Health Insurance Marketplace is typically in the late fall.
Open Enrollment Period (OEP)
he individual or organization that holds the insurance policy. This person or entity is responsible for paying premiums to the insurance company.
Policyholder
Is a fixed amount that policyholders pay at the time of receiving medical services. This is in addition to any other costs covered by the insurance plan.
Co-Payment/Co-Pay
Are claims submitted to the insurance company that are reviewed but not approved for reimbursement. Denials can occur for various reasons, such as services not being covered by the policy or lack of medical necessity.
Denied Claims
These terms are used to describe the order in which health insurance plans cover medical expenses. The primary insurance is the first to pay claims, followed by the secondary and tertiary insurance, if applicable.
Primary/Secondary/Tertiary
A healthcare professional or facility that offers medical services, such as hospitals, doctors, dentists, and pharmacies.
Provider
The person who is covered by the insurance policy and is entitled to receive benefits, including the payment of claims.
Beneficiary
Refers to healthcare providers, hospitals, or facilities that have contracts or agreements with an insurance company to provide services at negotiated rates to policyholders. Using in-network providers often results in lower out-of-pocket costs.
In Network
Is a unique identification number assigned to healthcare providers and organizations by the U.S. government. It's used for administrative and billing purposes.
NPI (National Provider Identifier)
Is a federal health insurance program in the United States primarily for individuals aged 65 and older, certain younger individuals with disabilities, and those with end-stage renal disease. It consists of various parts (A, B, C, and D) that cover hospital care, medical services, and prescription drugs.
Medicare
A document sent by the insurance company to the policyholder or the healthcare provider that provides a detailed explanation of how a claim was processed, including the amount paid and any patient responsibility.
Explanation of Benefits (EOB)
A coding system used to classify diseases, conditions, and medical procedures for billing and reimbursement purposes.
ICD-10 (International Classification of Diseases, 10th Edition)
Is the amount of money policyholders pay to their insurance company, typically on a monthly or annual basis, to maintain their health insurance coverage
Premium
Is the percentage of the medical costs that policyholders are responsible for paying after meeting their deductible. For example, if a policy has 20% co-insurance, the policyholder pays 20% of covered expenses, and the insurance company covers the remaining 80%.
Co-Insurance
Are health insurance plans designed for young, healthy individuals who want to protect themselves against major medical expenses but are willing to pay lower premiums and accept higher deductibles. These plans provide coverage for essential health benefits after the deductible is met.
Catastrophic Coverage Plan
The process used when an individual has multiple insurance policies to determine which one is the primary payer for healthcare claims.
Coordination of Benefits (COB)
A standardized code set used to describe medical procedures and services for billing and claims processing.
CPT (Current Procedural Terminology) Code