Glossary
Plain-language definitions for every term you will encounter. Browse by letter or filter by category.
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A
Allowed Amount
The maximum amount your insurer considers payable for a covered service, also called the eligible or negotiated amount.
Medical BillingAdverse Determination
A decision by your insurer to deny, reduce, or terminate coverage for a requested service or treatment.
Appeal ProcessACA
The Affordable Care Act, a federal law requiring insurers to cover preexisting conditions and offer essential health benefits.
Coverage TypesAppeal Deadline
The time limit, typically 180 days, within which you must file an appeal after receiving a denial from your insurer.
Appeal ProcessAdult Child Coverage
The ACA requirement allowing children to remain on a parent's health insurance plan until age 26.
Coverage TypesAppeal Letter
A written request to your insurer explaining why a denied service should be covered, including supporting medical evidence.
Appeal ProcessAuthorization Number
A reference code issued by the insurer confirming that a service has been pre-approved for coverage.
Coverage TypesAdjustment
A change made to a previously processed claim that modifies the payment amount or patient responsibility.
Medical BillingApplied Behavior Analysis
A therapy for autism spectrum disorder that many states require insurers to cover through autism insurance mandates.
Mental HealthAllowed Services
Healthcare services that your insurance plan covers as described in the plan document and summary of benefits.
Coverage TypesAccumulator
The running total of what you have paid toward your deductible and out-of-pocket maximum during the benefit year.
Insurance TermsAssignment of Benefits
Your authorization allowing the insurer to pay the healthcare provider directly instead of reimbursing you.
Medical BillingAnnual Limit
The maximum amount a plan pays in a year, prohibited for essential health benefits under the ACA.
Coverage TypesAmbulance Coverage
Insurance coverage for emergency and medically necessary ambulance transport, with varying copay and authorization rules.
Coverage TypesActuarial Value
The average percentage of total healthcare costs that a plan pays, used to define marketplace metal tier levels.
Insurance TermsB
Balance Billing
When an out-of-network provider bills you for the difference between their charge and the insurer's allowed amount.
Medical BillingBrand-Name Drug
A medication sold under the manufacturer's trademark name, typically more expensive than its generic equivalent.
Pharmacy BenefitsBiosimilar
A biologic medication highly similar to an already approved biologic, offering a lower-cost alternative for complex treatments.
Pharmacy BenefitsBronze Plan
A marketplace plan with the lowest premiums and highest out-of-pocket costs, covering about 60% of average expenses.
Insurance TermsBundled Payment
A single payment to providers covering all services related to a treatment or condition over a defined time period.
Medical BillingBehavioral Health
A broad term covering mental health, substance use disorders, and behavioral conditions treated through therapy and medication.
Mental HealthBenefit Year
The 12-month period during which your plan's deductible, copay accumulation, and out-of-pocket maximum apply.
Insurance TermsBenefit Maximum
The most your plan will pay for a specific type of service, such as dental or vision, within a benefit year.
Coverage TypesBenefit Verification
The process of confirming with the insurer what services are covered and what cost-sharing applies before treatment.
Coverage TypesC
Copay
A fixed dollar amount you pay for a covered healthcare service, such as $25 for a doctor visit or $10 for a prescription.
Insurance TermsCoinsurance
The percentage of costs you pay for a covered service after meeting your deductible, such as 20% of the allowed amount.
Insurance TermsCase Management
A coordinated approach where an insurer assigns a nurse or specialist to help manage complex or long-term care needs.
Coverage TypesCoordination of Benefits
Rules determining which plan pays first when you are covered by two or more health insurance policies.
Insurance TermsClean Claim
A properly submitted claim with no errors or missing information that can be processed without additional documentation.
Medical BillingCPT Code
Current Procedural Terminology codes that describe medical procedures and services for billing and insurance purposes.
Medical BillingCredentialing
The process of verifying a provider's qualifications, licenses, and history before they can bill an insurance company.
Medical BillingCOBRA
A federal law letting you continue your employer's group health insurance for up to 18 months after losing your job.
Insurance TermsClaim
A formal request submitted to your insurer by a provider or patient for payment of covered healthcare services.
Medical BillingClaim Denial
An insurer's decision to not pay for a submitted service, which triggers the right to file an internal appeal.
Appeal ProcessConcurrent Review
An ongoing evaluation by the insurer during a hospital stay to determine if continued inpatient care is medically necessary.
Coverage TypesCertificate of Coverage
A document proving you had prior health insurance, which may be needed when enrolling in a new plan.
Insurance TermsCatastrophic Coverage
The Medicare Part D phase after the donut hole where you pay only a small coinsurance for covered prescriptions.
Pharmacy BenefitsCHIP
Children's Health Insurance Program providing low-cost coverage for children in families earning too much for Medicaid.
Insurance TermsCost-Sharing Reduction
A subsidy that lowers deductibles and copays for qualifying low-income individuals enrolled in Silver marketplace plans.
Insurance TermsCatastrophic Plan
A low-premium, high-deductible marketplace plan available only to people under 30 or with a hardship exemption.
Insurance TermsConsolidated Billing
A billing method where one provider submits a single claim for all services during a bundled episode of care.
Medical BillingCommunity Rating
The ACA rule allowing premiums to vary only by age, location, tobacco use, and family size, not health status.
Insurance TermsClinical Guidelines
Evidence-based criteria that insurers use to determine whether a treatment or service meets medical necessity standards.
Coverage TypesCorrected Claim
A resubmitted claim that fixes errors in the original filing, such as wrong codes, dates, or patient information.
Medical BillingCharity Care
Free or discounted hospital care provided to patients who cannot afford to pay their medical bills.
Medical BillingCopay Accumulator Program
An insurer policy that excludes manufacturer copay assistance from counting toward your deductible or out-of-pocket maximum.
Pharmacy BenefitsCopay Maximizer Program
A program that spreads manufacturer copay assistance evenly across the year to reduce monthly out-of-pocket drug costs.
Pharmacy BenefitsCapitation
A fixed monthly payment per enrolled patient paid to a provider regardless of how many services the patient receives.
Medical BillingContinuation Coverage
The right to keep your employer health plan temporarily after a qualifying event like job loss, under COBRA or state laws.
Insurance TermsConversion Privilege
The right to switch from a group health plan to an individual policy without a health screening when group coverage ends.
Insurance TermsCreditable Coverage
Prior health coverage that counts toward reducing waiting periods when you switch to a new plan.
Insurance TermsCare Coordination
The organization of patient care across multiple providers and settings to ensure safe and effective treatment.
Coverage TypesCrisis Intervention
Emergency mental health services to stabilize a person in psychiatric crisis, covered as emergency care under most plans.
Mental HealthCoupon Card
A manufacturer discount card that reduces your out-of-pocket cost for a brand-name medication at the pharmacy.
Pharmacy BenefitsClaim Status Inquiry
A request to check the processing status of a submitted claim, available through insurer portals or phone support.
Medical BillingD
Deductible
The amount you pay out of pocket each year before your insurance begins covering its share of medical costs.
Insurance TermsDenial
Your insurer's refusal to pay for a service, which can be based on coverage exclusions, medical necessity, or errors.
Appeal ProcessDependent Coverage
Health insurance that covers your spouse, children, or other qualifying family members under your plan.
Insurance TermsDonut Hole
The Medicare Part D coverage gap where you temporarily pay a higher share of drug costs before catastrophic coverage begins.
Pharmacy BenefitsDual Eligible
A person enrolled in both Medicare and Medicaid who may receive additional benefits and reduced cost-sharing.
Insurance TermsDrug Exception Request
A formal request asking your insurer to cover a drug not on the formulary or at a lower cost-sharing tier.
Pharmacy BenefitsDRG
Diagnosis Related Group, a classification system used to determine fixed hospital payment amounts for Medicare inpatient stays.
Medical BillingDowncoding
When an insurer pays for a less expensive procedure code than the one submitted by the provider.
Medical BillingDuplicate Claim
A claim submitted more than once for the same service, which will be denied to prevent double payment.
Medical BillingDisease Management Program
An insurer program providing education and support for patients with chronic conditions to improve health outcomes.
Coverage TypesDependent Care FSA
A tax-advantaged account for paying child care or elder care expenses, separate from a healthcare FSA.
Insurance TermsDurable Medical Equipment
Reusable medical devices like wheelchairs, CPAP machines, and walkers that insurers cover when medically necessary.
Coverage TypesE
Explanation of Benefits
A statement from your insurer detailing what was billed, what they paid, and what you owe for a medical service.
Insurance TermsEPO
Exclusive Provider Organization plan that only covers in-network providers except in emergencies, with no referral requirement.
Insurance TermsExperimental Treatment
A procedure or therapy not yet widely accepted that insurers may deny as not meeting established standards of care.
Coverage TypesExternal Review
An independent review of a denied claim by a third party outside your insurance company, whose decision is binding.
Appeal ProcessEssential Health Benefits
Ten categories of services that ACA-compliant plans must cover, including hospitalization, prescriptions, and mental health.
Coverage TypesERA
Electronic Remittance Advice, the digital version of a payment explanation sent from the insurer to the provider.
Medical BillingExpedited Appeal
A fast-track appeal process required when a standard timeline could seriously jeopardize the patient's health.
Appeal ProcessExclusion
A specific service, condition, or treatment that your health insurance plan will not cover under any circumstances.
Coverage TypesERISA
The federal law governing employer-sponsored health plans, which preempts state insurance regulations for self-funded plans.
Insurance TermsEmergency Services
Care for conditions requiring immediate treatment, which must be covered at in-network rates regardless of provider status.
Coverage TypesEmployer Mandate
The ACA requirement that employers with 50 or more full-time employees offer affordable health insurance or pay a penalty.
Coverage TypesEmployee Assistance Program
A workplace benefit providing free short-term counseling and referral services for personal and work-related issues.
Mental HealthExplanation of Payment
A document sent to providers showing how an insurer processed and paid a claim, similar to an ERA.
Medical BillingEating Disorder Treatment
Coverage for conditions like anorexia and bulimia, subject to mental health parity rules for all levels of care.
Mental HealthEligibility Verification
Checking that a patient's insurance is active and the service is covered before providing care.
Coverage TypesF
FSA
Flexible Spending Account letting you set aside pre-tax dollars for medical expenses, with a use-it-or-lose-it rule.
Insurance TermsFormulary
The list of prescription drugs your insurance plan covers, organized by tiers that determine your cost for each medication.
Pharmacy BenefitsFee-for-Service
A payment model where providers are paid separately for each service or procedure they perform for a patient.
Medical BillingFinancial Assistance
Hospital programs offering reduced or free care to uninsured or underinsured patients who meet income qualifications.
Medical BillingG
Grievance
A formal complaint about your health plan's service, coverage decisions, or quality of care that is not a claim denial.
Appeal ProcessGeneric Drug
A medication with the same active ingredients as a brand-name drug, sold at a lower cost after the patent expires.
Pharmacy BenefitsGold Plan
A marketplace plan with higher premiums but lower out-of-pocket costs, covering about 80% of average expenses.
Insurance TermsGrace Period
A window, typically 30 to 90 days, during which your coverage continues even if your premium payment is late.
Insurance TermsGuaranteed Issue
The ACA requirement that insurers accept all applicants during open enrollment regardless of health status.
Coverage TypesGood Faith Estimate
A cost estimate that healthcare providers must give uninsured or self-pay patients before scheduled services under federal law.
Medical BillingH
HMO
Health Maintenance Organization plan requiring you to choose a primary care doctor and get referrals for specialist visits.
Insurance TermsHDHP
High Deductible Health Plan with lower premiums and higher deductibles that qualifies you to open a Health Savings Account.
Insurance TermsHSA
Health Savings Account allowing tax-free contributions to pay for qualified medical expenses when enrolled in an HDHP.
Insurance TermsHIPAA
The federal law protecting the privacy of your medical records and setting standards for electronic health data security.
Coverage TypesHealth Insurance Navigator
A trained professional who helps consumers understand insurance options and enroll in marketplace health plans for free.
Insurance TermsHRA
Health Reimbursement Arrangement, an employer-funded account that reimburses employees for medical expenses and premiums.
Insurance TermsHome Health Care
Skilled nursing or therapy services provided in your home, covered when ordered by a doctor and medically necessary.
Coverage TypesI
In-Network
Providers who have agreements with your insurer to charge negotiated rates, resulting in lower costs for you.
Insurance TermsInternal Appeal
A formal request to your insurer to reconsider a denied claim, reviewed by someone who was not part of the original decision.
Appeal ProcessIndependent Review Organization
A third-party entity that conducts external reviews of insurance denials using qualified medical professionals.
Appeal ProcessICD-10
International Classification of Diseases codes used to identify diagnoses and justify the medical necessity of services.
Medical BillingIndividual Mandate
The ACA requirement that most people maintain health insurance, though the federal penalty was reduced to zero in 2019.
Coverage TypesInterQual
A commercial clinical decision support tool widely used by insurers to evaluate medical necessity for admissions and procedures.
Coverage TypesInpatient Mental Health
Hospital-level psychiatric care requiring an overnight stay, subject to the same coverage rules as medical inpatient care.
Mental HealthIntensive Outpatient Program
A structured treatment program requiring several hours per day, multiple days per week, without an overnight stay.
Mental HealthItemized Bill
A detailed statement listing every individual charge for services, supplies, and medications during a healthcare visit.
Medical BillingInpatient Admission
A formal order by a doctor admitting you to the hospital as an inpatient, triggering different coverage rules than observation.
Coverage TypesL
M
Medical Necessity
The standard insurers use to determine if a treatment is appropriate, effective, and required for a patient's condition.
Coverage TypesModifier
A two-character code added to a CPT code to provide additional information about how a service was performed.
Medical BillingMarketplace
The federal or state exchange where individuals can shop for and enroll in ACA-compliant health insurance plans.
Insurance TermsMetal Tier
The four plan levels on the marketplace (Bronze, Silver, Gold, Platinum) that indicate how costs are shared between you and the plan.
Insurance TermsMental Health Parity
The legal requirement that insurers cover mental health and substance use services at the same level as medical services.
Mental HealthMHPAEA
The Mental Health Parity and Addiction Equity Act requiring equal coverage limits for mental health and medical benefits.
Mental HealthMedigap
A private supplemental insurance policy that helps cover Medicare cost-sharing like deductibles, copays, and coinsurance.
Insurance TermsMedicare
The federal health insurance program for people 65 and older or with certain disabilities, divided into Parts A through D.
Insurance TermsMedicare Advantage
A private insurance plan (Part C) that combines Medicare Parts A and B and often includes drug coverage and extra benefits.
Insurance TermsMedicare Part D
The Medicare prescription drug benefit that helps cover the cost of outpatient medications through private plans.
Pharmacy BenefitsMedicaid
A joint federal and state program providing health coverage to low-income individuals, families, and people with disabilities.
Insurance TermsMail-Order Pharmacy
A pharmacy service that delivers medications by mail, often at a lower cost for maintenance prescriptions.
Pharmacy BenefitsMedical Loss Ratio
The ACA requirement that insurers spend at least 80% of premiums on medical care, or issue rebates to enrollees.
Insurance TermsMedical Director
A physician employed by the insurer who reviews claims and makes coverage decisions based on medical necessity criteria.
Appeal ProcessMilliman Care Guidelines
A widely used set of evidence-based clinical criteria that insurers apply when reviewing medical necessity determinations.
Coverage TypesMedication-Assisted Treatment
Treatment for substance use disorders combining FDA-approved medications with counseling and behavioral therapies.
Mental HealthMedical Billing Advocate
A professional who reviews medical bills for errors and negotiates with providers and insurers on the patient's behalf.
Medical BillingMedical Debt
Unpaid medical bills that can be sent to collections, though recent rules limit their impact on credit reports.
Medical BillingMental Health Coverage
Insurance benefits for therapy, psychiatry, and psychological testing that must be equal to medical coverage under federal law.
Mental HealthManaged Care
A healthcare system where insurers contract with providers to deliver care at reduced costs with managed utilization.
Insurance TermsN
No Surprises Act
A 2022 federal law protecting patients from unexpected out-of-network bills for emergency and certain non-emergency services.
Medical BillingNPI
National Provider Identifier, a unique 10-digit number assigned to every healthcare provider for billing and identification.
Medical BillingNetwork Adequacy
The requirement that insurance plans maintain enough providers in their network to deliver timely care to all enrollees.
Coverage TypesNDC
National Drug Code, a unique identifier assigned to each medication product used for billing and inventory tracking.
Pharmacy BenefitsNon-Preferred Drug
A medication on a higher formulary tier with higher cost-sharing because cheaper alternatives are available.
Pharmacy BenefitsNon-Quantitative Treatment Limitation
A coverage restriction like prior authorization or step therapy that must be applied equally to mental and medical benefits.
Mental HealthO
Out-of-Pocket Maximum
The most you will pay in a year for covered services, after which your insurance pays 100% of allowed amounts.
Insurance TermsOut-of-Network
Providers without a contract with your insurer, typically resulting in higher costs and potential balance billing.
Insurance TermsOpen Enrollment
The annual period when you can sign up for or change your health insurance plan without a qualifying life event.
Insurance TermsOut-of-Network Reimbursement
The amount your insurer pays when you receive care from a provider outside the plan's network.
Medical BillingOutpatient Mental Health
Therapy, counseling, and psychiatric visits that do not require hospitalization, covered as an essential health benefit.
Mental HealthObservation Status
A hospital classification where you are technically an outpatient, which affects coverage for follow-up skilled nursing care.
Coverage TypesOut-of-Area Coverage
Benefits available when you need care outside your plan's service area, varying widely by plan type and situation.
Coverage TypesP
Premium
The monthly payment you make to keep your health insurance active, regardless of whether you use any services.
Insurance TermsPPO
Preferred Provider Organization plan allowing you to see any provider without referrals, with lower costs for in-network care.
Insurance TermsPOS
Point of Service plan combining HMO and PPO features, requiring referrals but allowing out-of-network care at higher cost.
Insurance TermsPrior Authorization
Approval required from your insurer before receiving certain services, medications, or procedures to confirm coverage.
Coverage TypesPreferred Provider
A doctor, hospital, or other healthcare provider who has contracted with your insurer to provide services at lower rates.
Insurance TermsPreexisting Condition
A health problem you had before your coverage start date, which ACA-compliant plans cannot use to deny coverage.
Coverage TypesPremium Tax Credit
A federal subsidy that reduces your monthly health insurance premium based on your income and household size.
Insurance TermsProspective Review
An insurer's evaluation of medical necessity before a service is provided, also known as prior authorization.
Coverage TypesPlan Document
The full legal contract describing all terms, conditions, exclusions, and benefits of your health insurance plan.
Insurance TermsPrimary Insurance
The insurance plan that pays first when you have coverage under two or more health plans.
Insurance TermsPharmacy Benefit Manager
A company that manages prescription drug benefits for insurers by negotiating prices and maintaining formularies.
Pharmacy BenefitsPreferred Drug
A medication on a lower formulary tier that the insurer encourages through reduced copays compared to non-preferred options.
Pharmacy BenefitsPharmacy Benefit
The portion of your health plan that covers prescription medications, including retail and mail-order pharmacy services.
Pharmacy BenefitsPre-Certification
Another term for prior authorization, requiring advance approval from the insurer before receiving certain services.
Coverage TypesPrimary Care Physician
Your main doctor who provides routine care, coordinates specialist referrals, and manages your overall health.
Coverage TypesPrudent Layperson Standard
The legal standard defining an emergency as any condition a reasonable person would believe requires immediate care.
Coverage TypesPreventive Care
Routine health services like screenings, vaccinations, and checkups that ACA plans must cover at no cost to you.
Coverage TypesPlatinum Plan
A marketplace plan with the highest premiums but lowest out-of-pocket costs, covering about 90% of average expenses.
Insurance TermsPlace of Service Code
A two-digit code identifying where a healthcare service was performed, such as office, hospital, or telehealth.
Medical BillingProvider Directory
A list of doctors, hospitals, and other providers in your insurance plan's network that you can search by specialty or location.
Coverage TypesPHI
Protected Health Information, any individually identifiable health data covered by HIPAA privacy protections.
Coverage TypesPrivacy Rights
Your legal right under HIPAA to access, amend, and control how your medical information is shared and used.
Coverage TypesPeer-to-Peer Review
A phone call between your doctor and the insurer's medical director to discuss why a denied service is medically necessary.
Appeal ProcessPatient Responsibility
The total amount you owe after insurance pays its portion, including deductible, copay, and coinsurance amounts.
Medical BillingPayment Plan
An arrangement to pay a medical bill in installments over time, often available interest-free from providers.
Medical BillingPrice Transparency
Federal rules requiring hospitals to publish standard charges for services and insurers to provide cost-estimator tools.
Medical BillingPartial Hospitalization Program
A day program providing intensive psychiatric treatment for patients who need more support than outpatient therapy.
Mental HealthParity Compliance
An insurer's adherence to federal laws requiring equal coverage of mental health and medical benefits.
Mental HealthPrior Authorization Denial
A refusal by the insurer to approve a requested service before it is performed, which can be appealed.
Appeal ProcessPartial Denial
An insurer's decision to cover some but not all of the requested services, reducing the approved scope of treatment.
Appeal ProcessPrescription Drug Coverage
The portion of your health plan that pays for medications, one of the ten essential health benefits under the ACA.
Pharmacy BenefitsPatient Assistance Program
A manufacturer program providing free or low-cost medications to patients who cannot afford them.
Pharmacy BenefitsPoint of Service Plan
A managed care plan allowing out-of-network use at higher cost, combining features of HMO and PPO plan types.
Insurance TermsPCORI Fee
A fee paid by health insurers and self-funded plans to fund the Patient-Centered Outcomes Research Institute.
Insurance TermsQ
Qualifying Life Event
A life change such as marriage, birth, or job loss that triggers a special enrollment period for health insurance.
Insurance TermsQuantity Limit
A restriction on the amount of medication your insurer will cover in a given time period for safety or cost reasons.
Pharmacy BenefitsQuantitative Treatment Limitation
A numerical limit on covered services like visit caps or day limits that must be equal for mental and medical benefits.
Mental HealthQualified Medical Expense
An IRS-defined healthcare cost that can be paid with tax-advantaged funds from an HSA, FSA, or HRA.
Insurance TermsR
Remittance Advice
A document from the insurer to the provider showing how each claim was processed, adjusted, or denied.
Medical BillingRetrospective Review
An insurer's evaluation of whether a service already provided was medically necessary and covered under the plan.
Coverage TypesReferral
A written order from your primary care doctor directing you to a specialist, required by HMO and some POS plans.
Coverage TypesRevenue Code
A four-digit code on hospital claims identifying where a service was provided or the type of facility charge.
Medical BillingRescission
The retroactive cancellation of your insurance policy, only allowed if you committed fraud or intentional misrepresentation.
Coverage TypesReconsideration
A request to the insurer to re-examine a denied or underpaid claim, often the first step before a formal appeal.
Appeal ProcessResidential Treatment
A structured live-in program for mental health or substance use treatment, often requiring prior authorization.
Mental HealthRetrospective Denial
A denial issued after care has already been provided, often due to lack of authorization or medical necessity disputes.
Appeal ProcessReimbursement
Payment from your insurer to you or your provider for covered healthcare services that have already been delivered.
Medical BillingRebate
A discount paid by drug manufacturers to insurers or PBMs after a medication is sold, reducing the insurer's net cost.
Pharmacy BenefitsRisk Pool
The group of people whose premiums and medical costs are combined to set rates and spread financial risk.
Insurance TermsS
Step Therapy
A policy requiring you to try cheaper medications first before your insurer will cover a more expensive alternative.
Pharmacy BenefitsSpecialty Pharmacy
A pharmacy that dispenses high-cost, complex medications requiring special handling, administration, or patient monitoring.
Pharmacy BenefitsSurprise Billing
An unexpected bill from an out-of-network provider at an in-network facility, now limited by the No Surprises Act.
Medical BillingSubrogation
Your insurer's right to recover payment from a third party who caused the injury or illness they covered.
Insurance TermsState Insurance Department
The state agency that regulates insurers and can investigate complaints about unfair denials or coverage practices.
Appeal ProcessSummary of Benefits and Coverage
A standardized document that explains your plan's benefits, cost-sharing, and coverage limitations in plain language.
Insurance TermsSpecial Enrollment Period
A window outside open enrollment when you can enroll due to a qualifying event like job loss, marriage, or birth.
Insurance TermsSecondary Insurance
The insurance plan that pays after the primary insurer, covering some or all of the remaining patient responsibility.
Insurance TermsSupplemental Insurance
An additional policy that helps cover costs your primary insurance does not pay, such as hospital cash or critical illness.
Insurance TermsSelf-Funded Plan
An employer health plan where the company pays claims directly instead of purchasing insurance from a carrier.
Insurance TermsSpecialist
A doctor focused on a specific area of medicine, such as cardiology or orthopedics, often requiring a referral to visit.
Coverage TypesSilver Plan
A marketplace plan with moderate premiums and costs, covering about 70% of average expenses and eligible for CSR subsidies.
Insurance TermsSuperbill
An itemized receipt from a provider listing diagnoses, procedures, and charges that you can submit for reimbursement.
Medical BillingSubstance Use Disorder
A condition involving problematic use of alcohol or drugs that insurers must cover at parity with medical conditions.
Mental HealthShort-Term Health Plan
A temporary insurance plan that does not have to comply with ACA rules, often with limited benefits and exclusions.
Insurance TermsSkilled Nursing Facility
A facility providing short-term rehabilitation and nursing care, covered by insurance only after a qualifying hospital stay.
Coverage TypesSpecialty Drug
A high-cost medication used for complex conditions that often requires special storage, handling, or administration.
Pharmacy BenefitsStop-Loss Insurance
Coverage purchased by self-funded employers to limit their financial exposure when claims exceed a set threshold.
Insurance TermsSecond Opinion
A consultation with another doctor about a diagnosis or treatment plan, covered by most insurance plans.
Coverage TypesT
Tier
A level within a formulary that determines your cost-sharing for a drug, with lower tiers having lower copays.
Pharmacy BenefitsThird-Party Administrator
A company that processes claims and handles administration for self-funded employer health plans.
Medical BillingTelehealth Services
Virtual doctor visits conducted by phone or video that most insurance plans now cover as a standard benefit.
Coverage TypesTimely Filing
The deadline by which a provider must submit a claim to the insurer, typically 90 days to one year after service.
Medical BillingTransitional Care
Services that help patients move safely between care settings, such as from hospital to home or skilled nursing.
Coverage TypesU
UCR
Usual, Customary, and Reasonable charges that represent the typical cost for a service in a geographic area.
Medical BillingUtilization Management
The process insurers use to evaluate the medical necessity, appropriateness, and efficiency of healthcare services.
Coverage TypesUrgent Care
Care for conditions needing prompt attention but not life-threatening, typically available at walk-in clinics.
Coverage TypesUpcoding
The improper practice of billing for a more expensive service than what was actually provided, which constitutes fraud.
Medical BillingUnbundling
The improper practice of billing separately for services that should be submitted together under a single code.
Medical BillingUsual Fee
The amount a provider typically charges for a service, which may be higher than what the insurer allows.
Medical BillingUncompensated Care
Healthcare services provided by hospitals that are never paid for, including charity care and bad debt.
Medical BillingV
W
Waiting Period
The time you must wait after enrolling before your health insurance coverage becomes effective, typically up to 90 days.
Coverage TypesWrite-Off
The portion of a charge that a provider agrees not to collect, often the difference between billed and allowed amounts.
Medical BillingWellness Program
An employer or insurer program offering incentives for healthy behaviors like exercise, screenings, and smoking cessation.
Coverage Types