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Medical Insurance
medical insurance terms
42
Health Care
Not Applicable
01/16/2017
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Term
premium
 Definition
The amount charged for a medical insurance policy.
Term
insurance benefits
 Definition
payments for medical services that can be submitted by an insurance company under a predefined policy issued to an individual or group of individuals
Term
lifetime maximum benefits
 Definition
the total sum that the health plan will pay out over the patient's life.
Term
rider
 Definition
a special provision or provisions that may be added to a policy to expand or limit benefits that would otherwise be payable
Term
UCR
 Definition
The usual, customary, and reasonable fee.
Term
usual fee
 Definition
the fee an individual physician most frequently charges for a service to private patients.
Term
customary fee
 Definition
The range of fees charged by most physicians in the community for a particular service.
Term
reasonable fee
 Definition
The generally accepted fee a physician charges for an exceptionally difficult or complicated service.
Term
prevailing charges
 Definition
The generally accepted fee a physician charges for an exceptionally difficult or complicated service.
Term
third-party payer
 Definition
A health plan or other party that agrees to carry the risk of paying for a patient’s medical services.
Term
assignment of benefits
 Definition
An authorization to an insurance company to make payment directly to the physician.
Term
acceptance of assignment
 Definition
An agreement by a physician to accept the amount established by Medicare, Medicaid, or a private insurer as full payment for covered services.
Term
schedule of benefits
 Definition
The list of services that are paid for and the amounts that are paid by the insurance carrier.
Term
overpayment
 Definition
Payment by the insurer or by the patient of more than the amount due.
Term
subscriber
 Definition
The person named as the principal in an insurance contract
Term
nonparticipating(nonPAR)provider
 Definition
A physician or other health-care provider who has not joined a particular insurance plan.
Term
participating (PAR) provider
 Definition
A physician or other health-care provider who has not joined a particular insurance plan.
Term
medical provider
 Definition
a licensed professional who performs medical procedures.
Term
coordination of benefits
 Definition
Prevents duplicate payment for the same service.
Term
allowed charge
 Definition
The maximum charge an insurance carrier or government program will cover for specific services.
Term
explanation of benefits (EOB)
 Definition
A document from an insurance carrier that shows how the amount of the benefit was determined.
Term
waiting period
 Definition
The initial period of time when a newly insured individual is not eligible to receive benefits.
Term
copayment (copay)
 Definition
The amount of money due from the subscriber to cover a portion of a bill.
Term
exclusions
 Definition
Expenses that may not be covered under the insured’s contract.
Term
utilization review
 Definition
Examination of services by an outside group.
Term
peer review organizations
 Definition
Groups of practicing physicians paid by insurance companies to review medical records with respect to effectiveness and efficiency.
Term
basic medical insurance
 Definition
Covers some or all nonsurgical services provided by a physician, whether in the office, the patient’s home, or a hospital.
Term
major medical insurance
 Definition
A policy designed to offset heavy medical expenses resulting from catastrophic or prolonged illness or injury.
Term
hospital coverage
 Definition
Pays for a hospital room, board, and special services in total or in part.
Term
surgical coverage
 Definition
Covers suturing, fracture reduction, aspiration, removal of foreign bodies, excisions, and incisions performed in a doctor’s office, a hospital, or elsewhere.
Term
disability protection
 Definition
Covers loss of income that results from illness.
Term
liability insurance
 Definition
Covers people injured in their homes or cars.
Term
indemnity plans
 Definition
The insurer pays the subscriber a set amount for each service or procedure performed because of illness or injury.
Term
group policies
 Definition
Cover groups of people under a master contract, which is generally issued to an employer for the benefit of the employees.
Term
service benefit plan
 Definition
Individuals who do not qualify for group policies may apply for individual policies.
Term
government plan
 Definition
government-sponsored insurance coverage for eligible individuals. Includes Medicare, Medicaid, Tricare and CHAMPVA
Term
Medicare Part A
 Definition
Medicare that covers hospital, nursing facility, home health, hospice, and inpatient care.
Term
Medicare Part B
 Definition
Medicare that covers outpatient services, services by physicians, durable medical equipment, and other services and supplies.
Term
Medicare Part D
 Definition
Medicare that provides outpatient prescription drug coverage, only through private insurers with no connection to the government.
Term
diagnosis-related groups (DRGs)
 Definition
Groups of procedures or tests related directly to a diagnosis.
Term
Medicare fee schedule (MFS)
 Definition
Providers participating in Medicare must accept the charges listed in this schedule as payment for covered services.
Term
Medicare supplements (Medigap policies)
 Definition
Private insurance contracts that supplement regular Medicare coverage.
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