Glossary of Terms
Allowed Amount:
The amount set by an insurance that they are willing to pay for a service and/or procedure.
Certificate of Credible Coverage:
A document provided to you by an insurance company after you drop their coverage, provided the coverage was a HIPAA qualified plan.
COB (Coordination of Benefits):
An arrangement in health insurance to discourage multiple payments for the same claim under two or more policies. When two or more group health insurance plans cover the insured and dependents, one plan becomes the primary plan and the other plan(s) the secondary plan(s).
Co-ins:
Coinsurance is the amount you are required to pay for medical care in a fee-for-service plan. The coinsurance rate is usually expressed as a percentage. For example, if the insurance company pays 80 percent of the claim, you pay 20 percent.
Contractual Adjustment:
A contractual adjustment is an adjustment made to reduce the billed charge to the amount an insurance company has contracted with the doctors’ office. Contractual adjustments are only made on services covered by a contracted insurance company.
Co-pay:
A type of insurance policy where the insured pays a specified amount of out-of-pocket expenses for health-care services such as doctor visits and prescriptions drugs at the time the service is rendered. However, unlike coinsurance, where the insured is required to pay a certain percentage of the covered costs, co-pay plans require the insured to pay a specified dollar amount.
Deductible:
Amount the insured must pay before the insurance will pay, up to the limits of the policy. The higher the deductible dollar amount due from the insured, the lower the premium.
Global Period:
A time period set aside before and after a surgical procedure is done. This includes the initial visit and any follow up visits. The global period varies from 10 days to 90 days depending on type of surgery.
Inclusive:
A procedure and/or service that is included in another procedure and/or service.
Maximum Benefit:
The maximum dollar amount an insurance plan will pay toward the cost of health care incurred by an individual or family in a specified policy year.
Non-Covered:
A service or procedure an insurance plan will not cover based on the plan benefits.
Payer:
The insurance company
PCP (Primary Care Physician):
A physician, chosen by an individual to serve as his or her health-care professional and capable of handling a variety of health-related problems, of keeping a medical history and medical records on the individual, and of referring the person to specialists as needed.
Pre-Existing Condition:
Most insurance companies define a pre-existing condition as: any condition for which the patient has already received medical advice or treatment prior to enrollment in a new medical insurance plan.
RBRVS (Resource-Based Relative Value Scale):
RBRVS is a data structure used to determine how much money medical providers should be paid. It is currently used by Medicare in the United States and by nearly all Health Maintenance Organizations (HMOs).
Self-pay:
The patient has no insurance coverage and will have to pay for the services out of pocket.
* Definitions taken from www.wiki.answers.com*