Another name for the insurer, insurance company, or underwriter of risk.
Healthcare and health insurance definitions.
Case management is typically used for members who have a catastrophic illness or injury or are receiving long-term or specialized care. Case managers help members navigate their plan’s benefits, get the services they need, and help to provide continuity of care and transition planning.
A document that provides proof of a person’s insurance coverage. Under HIPAA laws, health insurers must issue this certificate to individuals when their coverage ends under an employer-provided group health plan, or under certain individual policies.
Services (inpatient or outpatient) related to the treatment of addiction and/or substance abuse disorders.
A bill submitted by a provider (or a member) to an insurance company to establish that medical services were provided.
Healthcare facility that provides preventive, diagnostic, and treatment services to patients in an outpatient setting.
See coordination of benefits.
Acronym for Consolidated Omnibus Budget Reconciliation Act, a federal law that requires employers to offer continued health insurance coverage to employees whose health and dental insurance coverage terminates. COBRA applies only to groups of 20 or more employees; groups with fewer than 20 employees are subject to state continuation laws.
See certificate of creditable coverage.
Coinsurance is how much you owe for a covered healthcare service or prescription, calculated as a percentage of the allowed service amount. View our video, What is co-insurance?
An expression of dissatisfaction about a specific problem encountered by a member, or about a decision by the insurer (or agent acting on behalf of the insurer). A complaint must include a request for action to resolve the problem or change the decision.
Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a nonemergency caesarean section aren’t complications of pregnancy. See ACA Uniform Glossary
When people have more than one health insurance policy, this coordination indicates which insurance plan will pay the claim, or pay the claim first. There are different types of COB provisions. Some types of COB mean that both plans contribute to paying covered expenses and there may be little or no out-of-pocket cost to the member. Other COB provisions only compare the benefits of the two plans and ensure that the benefit is paid at the better of the two possible benefits. When benefits are coordinated, one plan pays benefits first (the “primary coverage”) and the other pays based on the remaining balance (the “secondary coverage”).
When a member is responsible for paying a portion of the cost of care via deductibles, copayments, or coinsurance.
Services or benefits provided through a health insurance plan.
Current procedural terminology are codes used by healthcare professions to identify the medical services provided to a member. CPT codes are usually listed on a member’s explanation of benefits (EOB) statement.