Compasatory Damages
Money awarded to the insure to compensate for actual loses.
Precertification
Pre-approval for admission on a elective non-emergency hospitalization.
Beneficiary
Person who is entitled to receive benefits/payment from a claim.
Batch Files
Files grouped based on the date, or by the individual they were processed by.
Common Accident Provision
One deductible is taken from all members involved in a accident.
Actuarial Statistic
Statistical studies concerned with insurance and loss including reinsurance.
Claim Files
Files for holding claims and other processing information.
Coinsurance Limit
If coinsurance reaches a certain level, all subsequent claims are paid 100% by the plan.
Gender Rule
The plan covering the male employee is considered primary and female plan is secondary.
Conversion Factor
Dollar amount determined for a specific service type or a particular region.
Reinsurance
Insurance that reimburses the employer when loses exceed a specific amount.
Unnecessary Surgery
Surgery recommended even though alternative treatment methods are available.
Aggregate
Total of all amounts paid towards the deductible by any member of the family.
Subrogation
The right for a portion of the recovery that the claimant may obtain from a third party.
Stoploss Insurance
Insurance that covers plans when there benefit payments exceeds a certain amount.
Full Credit Adjustment
Adjustment that completely reverses a claim payment.
Fee Schedule
Allowable amounts assigned to particular CPT codes.
Carryover Deductible
Payments towards deductible in the last three months are applied to next years deductible.
Benefit
Item covered by an insurance policy or amount paid on behalf of the recipient.
Concurrent Review
Determines whether length of time and scope of inpatient stay is justified.
Credible Coverage
Plans with similar coverage terms.
Global COB
Coordination of Benefits, applied to both medical and dental charges combined.
Insurance Speculation
Buying insurance plans for the purpose of making a profit.
Partial Credit Adjustment
An adjustment that partially reverses a claim payment.
Predetermination
Estimate of maximum benefits paid under the plan for services.