Sorry, you need to enable JavaScript to visit this website.

Office of Health Care Ombudsman and Bill of Rights

Office of Health Care Ombudsman and Bill of Rights

DC Agency Top Menu

-A +A
Bookmark and Share

Terms to Know

Appealing a Claim:  The process to fight a denied medical claim. Most insurance carriers have their own process and timeline.
Balance Billing:  The amount you could be responsible for (in addition to any co-payments, deductibles or coinsurance). If you use an out-of-network provider and the fee for a particular service exceeds the allowable charge for that service.
Carrier:  The insurance company that issues your insurance policy.
Carve-Out:  An independent health organization who manages medical/dental benefits separately from the plan’s medical benefits.
Claim:  An overview of care provided and a request for payment, typically submitted by the provider to the patient’s insurance company. This review process determines coverage of services and ultimate payment to the provider.
Co-Payment:  The dollar amount that an insured patient is expected to pay at the time of service.
Deductible:  A dollar amount an insured patient must pay before the insurer will make any benefit payments.
Denied Medical Claim:  Reject of a request for reimbursement of health care services delivered to the insured patient. The insurance company often informs the patient of the rejected claim and explains why the services are believed to be outside of the scoped of those covered in the insurance policy.
Effective Date:  The date your insurance is to actually begin. You are not covered until the policy’s effective date.
Exclusions:  Specific conditions, services or treatments for which a health insurance plan will not provide coverage.
Explanation of Benefits:  A statement sent from the health insurance company to an insured member listing services that were billed by a health care provider, how those charges were processed and the total amount of patient responsibility for the claim.
External Review:  External review is part of the health insurance claims denial process. It typically occurs when an independent third party reviews your claim to determine whether the insurer is obligated to pay. External review is one of several steps that comprise the appeal and review process.  It is performed after the appellant has exhausted the insurance company’s internal review process without success.
Financial Requirements:  e.g., deductibles, copayment, coinsurance, out-of-pocket maximums
Formulary:  A listing of drugs, classified by therapeutic category or disease class, that are considered preferred therapy for a given managed population and that  are to be used by an MCO’s providers. 
Fully Insured Plan:  Employer-sponsored insurance purchased through an insurance company. These plans are regulated by state insurance commissions.
Health Insurance Portability and Accountability Act (HIPAA):  A federal law that outlines the requirements that employer-sponsored group insurance plans, insurance companies and managed care organizations must satisfy in order to provide health insurance coverage in the individual and group health care markets.
Independent External Review:  An appeals review that is conducted by a third party that is not affiliated with the health plan or a providers’ association and has no conflict of interest or stake in the outcome of the review. This is usually the third level of review. This is often defined by state law. 
In-Patient:  A term used to describe a person admitted to a hospital for at least 24 hours. It may also be used to describe the care rendered in a hospital when the duration of the stay is at least 24 hours.
MCOs (Managed Care Organizations):  A continuum of organizations that provide managed care, each operating with slightly different business models. Some organizations are made of physicians, while others are combinations of physicians, hospitals and other providers.
Medicaid:  A joint federal and state program that provides hospital expense and medical expense coverage to the low-income population and certain aged and disabled individuals.
Medically Necessary:  Medical services that is essential or required for the diagnosis and/or treatment of a medical condition.
Network:  The group of physicians, hospitals, and other medical care professionals that a managed care plan has contracted with to deliver medical services to its members.
Non-Quantitative Limitation:  Any non-financial treatment limitation imposed by a health plan that limits the scope of duration of treatment (i.e. preauthorization, medically necessity, utilization review, etc.).
Out-of-Plan/Out-of-Network:  Physicians, hospitals and other health care providers that are not contracted with the plan or insurer to provide health care services at discounted rates. Depending on an individual’s plan, expenses incurred by services provided by out-of-plan health care professionals may not be covered, or may be only partially covered.
Out-Patient:  Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other in-patient facility.
Partial Hospitalization Services:  Also referred to as “partial hospital days,” this is a health care term used to refer to out-patient services performed in a hospital setting.
Pre-Authorization:  Confirmation of coverage by the insurance company for a service or product before receiving the service or product from the medical provider. (Also known as prior authorization).
Provider Payment:  Amount of money paid to the health care provider by the insurance company.
Qualified Medicare Beneficiary/Medicare Savings Program (QMB):  This program can help Medicare beneficiaries with their Medicare expenses including monthly premiums, co-insurance, co-payments and deductibles. 
Quantitative Treatment Limitation:  Financial requirements such as co-payments, co-insurance, deductibles that must be paid by plan participants.
Reasonable and Customary Fees/Usual and Customary Fees:  The average fee charged by a particular type of health care practitioner within geographic area. These fees are often used by insurers to determine the amount of coverage for health care provided by out-of-network providers. The individual may be responsible for any co-payment, co-insurance and deductible, as well as any remaining portion of the provider’s fee that is not covered by the Reasonable and Customary Fee.
Reason Codes:  A letter or number system typically presented and defined at the bottom of an Explanation of Benefits (EOB), used to explain how the insurance claim was processed. These codes are very important in understanding why the insurance company denied all or part of your claim.
Self-Insured Plan (ERISA):  A plan offered by employers who directly assume the major cost of health insurance for their employees. Self-insured employee health benefit plans are exempt from many state laws and instead are subject to federal (ERISA) law.
Summary Plan Description or Document:  A description of the benefits included in your health plan.
Treatment Limitations:  Limits based on frequency of treatment, number of visits, days of coverage, days in a waiting period.
(2)[from September 2010 – First Edition – Parity Implementation Coalition – “Terms To Know” – (Pages 53-55)]