Health Insurance Glossary

Knowing these terms not only empowers you but can also potentially tilt the balance in your favor during appeals. Keep this guide handy, and perhaps share it with someone navigating similar terrain. Knowledge, after all, is the best pre-existing condition to have.
Health Insurance Glossary

The Glossary of Health Insurance Claim Appeals


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.


  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.

Great! You’ve successfully signed up.
Welcome back! You've successfully signed in.
You've successfully subscribed to FLYRCM - Innovating Healthcare Revenue Cycle with AI-Driven Workflows.
Your link has expired.
Success! Check your email for magic link to sign-in.
Success! Your billing info has been updated.
Your billing was not updated.