Health Insurance Glossary

The Glossary of Health Insurance Claim Appeals

Introduction

Navigating the labyrinth of health insurance claim appeals can be as complex as the healthcare system itself. But, take a moment. This is your guidebook, one that not only demystifies jargon but also equips you to tackle those appeal letters with confidence. Let's get started.

Glossary

1. Appeal: A formal request to an insurance company to reconsider a decision it has made regarding coverage.
2. Beneficiary: The individual receiving the medical services covered under an insurance policy.
3. Claim: A request submitted to an insurance company for payment for services rendered.
4. Claim Adjustment: The process of modifying a claim's payout, based on policy rules or errors found.
5. Claim Denial: A decision by an insurer not to cover a particular service or treatment.
6. Coding Errors: Incorrect or incomplete medical codes that lead to claim denial or adjustment.
7. Copay: The fixed amount paid by a beneficiary at the time of service.
8. Coverage Criteria: Guidelines established to determine what is and isn’t covered under a policy.
9. Deductible: The amount you pay for medical services before your insurance begins to cover costs.
10. Denial Letter: A document from the insurer explaining why a claim was denied.
11. EOB (Explanation of Benefits): A document that details what the insurance covered and what the patient owes.
12. External Review: A review of the claim by an entity not associated with the insurance company.
13. First-level Appeal: The first formal step in the appeals process, typically a review by the insurer.
14. Grace Period: Additional time given to make a late payment without losing coverage.
15. Independent Review Organization (IRO): A third-party reviewer for insurance claim appeals.
16. In-network: Services provided by healthcare providers who are part of an insurance plan’s network.
17. Out-of-network: Services from providers not in the insurance plan’s approved network.
18. Preauthorization: Prior approval needed for certain medical services.
19. Premium: Monthly or annual payments made to maintain insurance coverage.
20. Second-level Appeal: A further appeal step, usually involving external reviewers or arbitration.
21. Underpayment: A situation where the insurance company pays less than what was claimed.
22. Utilization Review: The process of evaluating the necessity and efficiency of medical services.
23. Affordable Care Act (ACA): U.S. legislation aimed at improving access to healthcare and reducing costs.
24. Appeal Timeline: The period within which you must file an appeal, usually specified in your policy.
25. Bad Faith: When an insurer intentionally denies or delays payment of a legitimate claim.
26. Capitation: A payment model where providers receive a set fee per patient, regardless of treatment provided.
27. Coinsurance: The percentage of healthcare costs you're responsible for after your deductible is met.
28. Coordination of Benefits (COB): When more than one insurance policy covers the individual, COB determines which plan pays first.
29. Credentialing: The process of verifying the qualifications of healthcare providers in an insurance network.
30. Dependent: Family members covered by a primary insured person's health insurance plan.
31. Drug Formulary: A list of prescription drugs covered by an insurance policy.
32. ERISA (Employee Retirement Income Security Act): Federal law that governs employer-sponsored insurance plans.
33. Exclusions: What is not covered by an insurance policy, detailed in the fine print.
34. FSA (Flexible Spending Account): An account that lets you set aside pre-tax dollars for specific health costs.
35. Grandfathered Plan: Health insurance plans that were in existence before the ACA and haven't substantially changed.
36. Grievance: A formal complaint filed against an insurance company for unsatisfactory services or treatment.
37. Health Savings Account (HSA): A tax-advantaged account to help you save for medical expenses.
38. High-Deductible Health Plan (HDHP): A plan with a higher deductible and generally lower premiums.
39. Lifetime Maximum: The maximum amount an insurance company will pay over the life of a policy.
40. Medically Necessary: Treatments or procedures that are essential for diagnosis or treatment, as defined by the insurer.
41. Out-of-Pocket Maximum: The most you could pay in a year for covered services.
42. Policyholder: The individual or entity that holds and is responsible for an insurance policy.
43. Pre-existing Condition: A health issue that existed before the start of an insurance coverage.
44. Prioritization: The ranking of appeal urgency by the insurer, often based on medical necessity.
45. Provider Network: The facilities, providers, and suppliers your insurer has contracted with.
46. Referral: A recommendation from a healthcare provider to see a specialist or get certain services.
47. Reimbursement: Payment made to the insured or healthcare provider after services are rendered.
48. Rider: An addition to an insurance policy that provides extra coverage or exclusions.
49. Short-term Health Plan: Coverage that lasts for a limited period, usually less than a year.
50. Tiered Network: A network where providers are grouped by the insurer based on certain criteria, often including cost.
51. Stop-Loss: The point at which your insurance begins to cover 100% of your healthcare costs, after you've reached your out-of-pocket maximum.
52. Subrogation: The process where your insurer seeks repayment from a third party responsible for a claim they've already paid.
53. Summary of Benefits and Coverage (SBC): A simplified explanation of a health plan's benefits and coverage.
54. Supplemental Insurance: Additional insurance that covers gaps in your primary health insurance plan.
55. Third-Party Administrator (TPA): An external organization that manages claims processing and other functions for a health insurance plan.
56. Underwriting: The process insurers use to determine eligibility and premiums based on an applicant’s risk profile.
57. Urgent Care Appeal: An expedited appeal process for situations where standard timelines could jeopardize the patient's health.
58. Value-Based Care: A healthcare model where providers are paid based on patient outcomes rather than services rendered.
59. Waiting Period: The time you must wait after enrolling in a plan before coverage becomes effective.
60. Waiver of Premium: A clause that allows you to stop paying premiums under certain conditions, such as becoming disabled, while still retaining coverage.
61. Walk-in Clinic: Healthcare centers that provide treatment without an appointment, often not covered by insurance.
62. Wellness Programs: Health promotion initiatives offered by insurance companies to improve general well-being and reduce healthcare costs.
63. X-Mod (Experience Modification Factor): A multiplier applied to your premium based on past claims, used primarily in workers' compensation insurance.
64. Zero Balance Bill: A statement confirming that no additional payment is due for covered services after insurance adjustments.
65. 5010 Standard: A set of electronic health transaction protocols required by the Health Insurance Portability and Accountability Act (HIPAA).
66. 837P and 837I: Standard forms for healthcare claims and hospital billing, respectively, used in electronic transactions.
67. Actuarial Value: The percentage of total average costs for covered benefits that a plan will cover.
68. Balance Billing: Charging the patient for the difference between the provider’s charge and the allowed amount.
69. Catastrophic Plan: Health insurance coverage designed for individuals under 30 and others exempt from ACA mandates.
70. Direct Provider: A healthcare provider that has a direct contractual relationship with an insurance company.
71. Inpatient vs. Outpatient: Distinguishes whether a patient requires admission to a hospital or can be treated on an ambulatory basis.
72. Navigator: An individual or organization trained to help consumers, small businesses, and employees explore health coverage options.
73. Point-of-Service (POS): A type of plan where you pay less if you use healthcare providers belonging to the plan’s network.
74. Risk Pool: A group of individuals whose healthcare costs are combined to calculate premiums.
75. Binding Arbitration: A legal process where a neutral third party resolves a dispute and the decision is final and binding for both parties.
76. Case Management: A collaborative process that assesses, plans, and facilitates healthcare services for individual needs.
77. Consumer Assistance Program: Programs designed to help consumers file complaints or appeals against insurance companies.
78. Cost-Sharing: The share of healthcare expenses the insured must pay, including deductibles, copayments, and coinsurance.
79. Critical Illness Insurance: A policy offering a lump-sum payment upon diagnosis of one of the critical illnesses specified in the policy.
80. Data Matching Issue: An inconsistency between data submitted to the insurance company and federal records, often leading to claim denials or delays.
81. Essential Health Benefits: A set of health care service categories that must be covered by most plans under the ACA.
82. Fee-for-Service: A payment model where providers are paid separately for each service rendered.
83. Gatekeeper: A term for primary care physicians who are the first point of contact and must refer patients to specialists.
84. Health Home: A team-based healthcare delivery model aimed at providing comprehensive and continuous healthcare to patients.
85. Health Reimbursement Arrangement (HRA): An employer-funded account that reimburses employees for medical expenses.
86. Incurred But Not Reported (IBNR): Claims that have been incurred but not yet reported to the insurance company.
87. Indemnity Plan: An insurance plan where the carrier pays a set portion of your total charges, regardless of the service or care received.
88. Job-Based Insurance: Health insurance that is offered through an individual's employer.
89. Lawfully Present: The term for individuals in the United States who have legal immigration status, including those with visas and green cards.
90. Lowest Cost Bronze Plan: The cheapest bronze plan available in a Marketplace, used as a benchmark for calculating subsidies.
91. Minimum Essential Coverage (MEC): The type of coverage needed to avoid the penalty for not having insurance under the ACA.
92. Non-Admitted Insurer: An insurance company that hasn't been approved by the state's insurance department but can still sell insurance.
93. Open Enrollment Period: A set period during which you can enroll in or change your health insurance plan.
94. Qualified Health Plan (QHP): An insurance plan certified by the Health Insurance Marketplace, providing essential health benefits and following established limits on cost-sharing.
95. Rescission: The retroactive cancellation of a health insurance policy, often due to fraud or intentional misrepresentation.
96. Self-Insured Plan: A type of plan where the employer assumes the financial risk for providing health insurance benefits.
97. Special Enrollment Period: A time outside of open enrollment when you can sign up for health insurance due to specific life events like marriage, birth, or job loss.
98. State Continuation Coverage: State laws that allow you to continue your health coverage after an employment ends, similar to federal COBRA but varies by state.
99. Telemedicine: The delivery of healthcare services via electronic means, such as phone or video conferencing.
100. Tiered Formulary: A drug list that categorizes medications into different tiers based on cost and necessity, impacting your out-of-pocket costs.

With this extended glossary, you're now equipped with a more comprehensive understanding of health insurance claim appeals. Use this lexicon as a tool to challenge denials, decode letters, and navigate complex healthcare bureaucracies. It's more than just terminology; it's your roadmap to informed advocacy in your healthcare journey.