Healthcare Terms Made Simple
These definitions apply in most cases. Some healthcare plans may use terms differently. Please check to see how your plan defines terms.
Admission - The admittance of a patient to a licensed hospital.
Appeal - Any written communication from a member that clearly expresses that he or she wants to present his or her case for review.
Authorized Service - A covered benefit that has been approved by your managed care.
Benefits Package or Benefit Schedule Summary - Description of covered health care services that your managed care plan will provide for you and your family.
Claim - Information submitted by you, your doctor, or the hospital. It documents the medical services you or your family member received. This information is used to process payment to you or the healthcare provider.
Co-insurance - A form of cost sharing. After your deductible has been met, the plan will begin paying a percent of your bills. The remaining amount, known as co- insurance, is the portion due by the patient.
Coordination of Benefits - A rule that applies if you are covered under more than one healthcare plan. Payment of benefits must be managed by the plans to stop duplication of benefits.
Copayment (CoPay) - A set fee the member pays to providers at the time services are provided. Co-pays are applied to emergency room visits, hospital admissions, office visits, etc. The patient should be aware of the co-payment amounts before services are received.
Dependent - A person enrolled in a managed care plan who is a member of your immediate family.
Deductible - The dollar amount of medical bills that the member must accumulate before the insurance plan pays benefits. For example, if a member's policy has a $500 deductible, the member must pay $500 out-of-pocket before the insurance company will pay benefits. Once the patient has met their deductible, the carrier usually pays a percent of the bill. The patient is liable for any unpaid amount. Deductibles are yearly, usually starting in January.
Eligible Member - A person covered by an insurance plan.
Emergency - The sudden and unexpected medical condition that would lead to one or more of the following:
- Serious impairment (risk) to the person's bodily functions or organs,
- Serious threat to life or limb or harm to others, or
- In the case of a pregnant woman, cause serious risk to the health of the mother or unborn child.
Explanation of Benefits (EOB) - The statement sent to you by your health plan. It outlines the services you received, how much is paid to the provider(s), and how much you are responsible for paying.
Health Maintenance Organization (HMO) - An insurance plan made up of a network of primary care doctors, hospitals, and other specialists. Their services are available to the insurance plan's members. Members are not usually covered if they receive care from providers who do not have a contract with the HMO.
Hospital - A facility that provides medical inpatient and outpatient health care services.
Managed Care - A variety of health care financing and delivery systems. They are designed to limit costs and improve the quality of health care services.
Medically Necessary or Medically Needed - Services that you must have for the treatment of an illness or injury as determined by your doctor.
Member - A person who is covered under a benefit contract.
Member Expense - Any amounts that are the member's responsibility to pay the hospital or doctor according to the member's benefit contract. This includes copayments, coinsurance and deductibles.
Network - A group of doctors or healthcare providers who agree to provide care to members and to abide by the rules of the insurance plan.
Non-Participating Provider - A health care professional or facility that does not have a written participating agreement with an insurance plan.
Out-of-Network Provider or Services - A provider is out-of-network if he or she is not listed as a "preferred provider" or is not contracted with your health plan. A service is out-of-network if it is not covered by your health plan. Out-of-pocket costs for the patient are often higher when the patient has care or services outside of the health plan's network.
Participating Provider - A health care professional or facility that has a written agreement with an insurance plan to participate in the plan.
Point-Of-Service (POS) Plan - A form of HMO that provides some coverage for services provided by doctors who are not included in the health plan's network.
Pre-Certification - A process that requires doctors to obtain approval from a patient's health plan before the patient is admitted to the hospital or receives certain services. The health plan names specific service that must be approved ahead of time. Examples of services requiring pre-certification include, but are not limited to: inpatient admissions; physical therapy, occupational therapy, and speech therapy; some radiology services; out-of-network services; and home healthcare services. This is also called pre-admission certification or prior authorization. Check with your health plan to be sure your doctor's office or other health care provider has completed the pre-certification process.
Preferred Provider Organization (PPO) - This is a group or network that contracts with certain healthcare providers and facilities to provide services at discounted rates. You may choose a doctor or hospital within this network; or in some instances, you may choose to see a healthcare provider outside of the health plan's network. However, choosing to see an out-of-network provider usually has higher out-of-pocket costs for you, the member.
Primary Care Physician (PCP) - A doctor who devotes most of his or her practice to family or general medicine. In an HMO, the PCP serves as the gatekeeper who controls a patient's access to care.
Referral - The process by which a doctor, usually your primary care physician (PCP), sends you to see a specialist or to another healthcare facility for treatment or additional healthcare services. Most health plans require your primary care doctor to "authorize" all referrals to other providers. If your health plan requires you to choose a primary care doctor to manage your care, a referral is often required from your PCP before you may receive other healthcare services. Any time you receive services from a provider other than your PCP, he or she must call the health plan or send in a referral form to permit a visit to another provider. It is important for the referral process to be complete before you go to an appointment. The health plan will not pay for services you receive from a specialist if your PCP has not authorized it. Check with your health plan to be sure that your PCP has completed the referral authorization process.
Specialist - A doctor to whom you may be referred by your primary care provider for specialty health care services.