Claim
tool used to request insurance payment under an insurance contract
Adjudicate
to settle judicially as in determination of payment for an insurance
Adjuster
Employee of an insurance carrier to whom a case is assigned and who follows the case until it is adjusted, or settled; grants verbal authorization in workers' compensation cases for testing, procedures, surgeries, and referrals
Advance Beneficiary Notice (ABN)
Waiver of liability form provided by the physician's office and given to Medicare beneficiaries to be signed prior to services being rendered that may be deemed not medically necessary and therefore not paid by Medicare
Agenda
a list of items to be discussed at a meeting
Beneficiary
One who qualifies for health insurance to receive medical benefits
Benefit List
List of benefits, that is, services and procedures that are covered under the insurance plan or program
Birthday Rule
Informal procedure adopted by the health industry, which is used to determine the primary insurance plan when both parents cover a child. The health plan of the person whose birthday (month and day, not year) falls earlier in the calendar year will pay first, and the plan of the other person covering the dependent will be the secondary payer.
Clearinghouse
Centralized location where claims are received, edited, and distributed electronically to insurance companies
Conversion Privilege
Clause in a group insurance policy that allows the insured to continue the same or lesser coverage under an individual policy
Coordination of Benefits (COB)
A clause in an insurance policy that explains how the policy will pay if more than one insurance policy applies to the claim.
Deductible
Amount the insured must pay in a calendar or fiscal year before policy benefits begin
dependents
Under an insurance contract, the spouse and children of the insured; in some cases, domestic partners
exclusions
specific hazards listed in an insurance policy for which the insurance company will not pay
Fiscal Intermediary
Contractor that processes and pays provider claims on behalf of state or federal agencies or insurance companies; also called fiscal agent
Grace Period
specified time interval after a premium payment is due in which the policyholder may make such payment during which the protection of the policy continues
insurance agent
Representative of an insurance company licensed by the state who solicits, negotiates, or effects contracts of insurance and services the policyholder for the insurer
insurance application
Signed statement of facts requested by an insurance company on the basis of which it decides whether or not to issue an insurance policy; it becomes part of the health insurance contract if a policy is issued
insured
Individual or organization who contracts for a policy of insurance and is protected in case of loss of property, life, or health under the terms of the insurance policy
limitations
Provision of an insurance policy that lists exceptions or reductions to specific coverage
major medical
Insurance policy especially designed to offset heavy medical expenses resulting from catastrophic or prolonged illness or injury
Medicare Administrative Contractor (MAC)
Insurance carriers who contract to pay Medicare Part B claims; formerly called fiscal agents
National Provider Identifier (NPI)
Ten-digit number, mandated by HIPAA and issued on a lifetime basis as a standard unique health identifier for health care providers, clearinghouses, and plans who conduct electronic transactions (may be used on paper claims); used by Medicare, Medicaid, TRICARE, CHAMPVA, and may be adopted by private insurance carriers
Partial Disability
Illness or injury that prevents a person from performing one or more of the functions of a regular job; may be temporary or permanent
Permanent disability (PD)
Illness or injury that is not resolved and prevents an insured person from performing all the functions of a regular job
preexisting condition
An injury that occurred, a disease that was contracted, or a physical condition that existed before the issuance of a health insurance policy
premium
Payment made on a regular schedule to keep an insurance policy in force
provider
A person or institution that gives medical care
Temporary disability (TD)
Illness or injury that temporarily prevents an injured person from performing the functions of a regular job
Third-party payer
party other than the patient who assumes responsibility for paying the patient's bills
time limit
Period of time in which a notice of claim or proof of loss must be filed
Total Disability
Illness or injury that prevents a person from performing the duties of his or her occupation or from engaging in any other type of work for remuneration
veteran
One who has served in the United States Armed Forces and has received an honorable discharge
Waiting Period
Time that must elapse before benefits for sickness or accident become payable
waiver
Attachment to an insurance policy that excludes certain illnesses or disabilities that would otherwise be covered
managed care
A health care system whose goals are to provide cost effective quality care.
Copayment
a small fixed fee paid by the patient at the time of an office visit
Coinsurance
the sharing of expenses by the policyholder and the insurance company
Medicaid
A federal and state assistance program that pays for health care services for people who cannot afford them.
Medicare
A federal program of health insurance for persons 65 years of age and older
Tricare
U.S. government health insurance plan for all military personnel
CHAMPVA
Civilian Health and Medical Program of the Department of Veterans Affairs
workmen's comp
money paid to workers who were injured on the job and are unable to work