Glossary
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Medical Insurance Glossary
A
B
C
D
E
F
G
H
I
L
M
N
O
P
Q
R
S
T
U
W
X
A
access
accident
accrete
accumulation period
accumulators
actual charge
actuary
acute care
Administrative Services Only Agreement
admit
adverse selection
agent
aggregate deductible
allowable charge
allowable costs
ambulatory care
ambulatory setting
ancillary fee
ancillary product
ancillary service
annual limit
appeal
approved health care facility or program
ASO
assignment of benefits
authentication
authorization
authorization appeal
average wholesale price
AWP
B
balance billing
beneficiary
benefit
benefit grouper
benefit level
benefit rider
benefit year
benefits package
birthday rule
board-certified
board-eligible
broker
C
CAP
capitation
CARC
carrier
carry-over provision
carve-out
case management
CDHC
Center for Medicare and Medicaid Innovation
Centers for Medicare and Medicaid Services
certificate of coverage
charge amount
chronic
claim
Claim Adjustment Reason Code
claim attachment
claim status
claims examiner
CLIA
clinical decision support
Clinical Laboratory Improvement Amendments
clinical review
CMMI
CMS
COB
COBRA
COB-savings eligible
coinsurance
concurrent review
Consolidated Omnibus Budget Reconciliation Act
consumer-driven healthcare
contract
coordination of benefits
coordination of benefits savings eligible
copay
copayment
cost sharing reduction
cost-sharing
coverage
coverage end date
coverage levels
coverage limits
coverage tier
covered services
D
date of service
deductible
deductible carry-over credit
Department of Health and Human Services
dependent
dependent coverage
designated mental health provider
designees
diagnosis code
diagnosis-related group
disease management
DME
DRG
drug maintenance list
Drug Utilization Review
duplicate coverage
DUR
durable medical equipment
E
effective date
electronic medical record
eligibility
eligibility date
eligibility requirements
eligible
eligible dependent
eligible employee
eligible expenses
eligible person
embedded deductible
emergency condition
emergency medical transportation
emergency room
employee certificate of insurance
employee contribution
employer contribution
employer-sponsored coverage
EMR
encounter
enrollee
enrollment
enrollment period
EOB
excluded services
Explanation of Benefits
F
family deductible
fee schedule
Fee-for-Service reimbursement
Form CMS-1500
G
gatekeeper
generic drug
global payments
grace period
grandfathered plan
grievance
group
group health coverage
guaranteed issue
H
HCPCS
HDHP
health insurance exchange
Health Insurance Marketplace
Health Insurance Oversight System
Health Insurance Portability and Accountability Act
health maintenance organization
health plan
health savings account
health service agreement
Healthcare Common Procedural Coding System
Healthcare Effectiveness Data and Information Set
healthcare provider
HEDIS
high deductible health plan
HIOS
HIPAA
HIX
HMO
home healthcare
hospice care
hospital benefits
hospitalization
hospitalization insurance
HSA
I
IBNR
ICD-10
ICD-9
incurred but not reported
indemnity plan
individual and family health insurance
individual deductible
in-network
inpatient care
integrated delivery system
interaction
intermediate care
International Classification of Diseases ninth revision
International Classification of Diseases tenth revision
L
lab or x-ray
lapse
length of stay
lifetime limit
lifetime maximum
limitations
long-term care
LOS
M
managed care
mandated benefits
max duration or maximum duration
maximum allowable
Medicaid
Medicaid reclamation claim
Medical Loss Ratio
medical necessity
medical savings account
Medicare
Medicare beneficiary
Medicare supplemental policy
member
minimum value
MLR
MSA
N
National Committee for Quality Assurance
National Drug Code
NCQA
NDC
network
network provider
non-duplication of benefits
non-embedded deductible
non-par provider
non-participating provider
nursing home
O
office visit
OnDemand
OOA
OOP
open enrollment period
originator
OTC drugs
out-of-area
out-of-network
out-of-pocket
out-of-pocket maximum
outpatient care
outpatient surgery
over-the-counter drugs
P
paid amount
par provider
partial disability
partial hospitalization services
participating provider
part-time employee
Patient Protection and Affordable Act
patient registry
patient safety
patient-cemtered medical home
payer
payment integrity
PBM
PCMH
PCP
peer review
peer-to-peer review
pended claim
per diem
per member per month
periodic health exam
personal health record
Pharmacy Benefit Manager
PHR
physical therapy
place of service
plan name
point of service plan
policy
policy term
policyholder
population health
POS plan
post-adjudication
PPACA
PPO
practical nurse
practitioner
pre-adjudication
pre-certification
pre-existing condition
pre-existing condition exclusion
preferred provider organization
premium
prescription drug coverage
prescription medication
preventive benefits
preventive care
preventive services
primary care
primary care physician
primary coverage
prior authorization
probationary period
product template
provider
provider network
provider write-off
Q
QHP
qualified health plan
qualifying life event
quality assurance
R
RA
RARC
rating process
reasonable and customary charges
referral
referral services
registered nurse
reinsurance
remittance advice remark codes
remitttance advice
rendering physician
renewal
renewal date
restoration request
retrieval request
retrospective review
rider
risk
S
sanction
SBC
second surgical opinion
secondary care
secondary coverage
secondary payer
self-funded insurance plan
service area
service provider
short-term plan
SIC code
skilled nursing care
skilled nursing facility
small group market
SPD
speciallty
Standard Industrial Classification codes
stop loss insurance
subrogation
subscriber
Summary of Benefits and Coverage
Summary Plan Description
T
third-party administrator
third-party payer
TPA
treatment facility
U
UB04
UCR charge
underwriting
usual customary and reasonable charge
utilization management
Utilization Management Review
W
waiting period
waiver
waiver of premium
wellness program
WHO
workers' compensation
World Health Organization
X
X12 837