1. | The amount a customer pays towards a doctor’s visit. The amount can vary based on the health plan coverage terms and the type of covered health service rendered. | A. | Appeal |
2. | The Health Insurance Portability and Accountability Act of 1996. | B. | Explanation of Benefits (EOB) |
3. | A patient's request that the health plan review or change a claim decision. | C. | Date of service |
4. | The money paid to a health plan for coverage. | D. | HIPAA |
5. | A specified dollar amount that must be incurred before the Plan will pay any amount for any benefit during each Benefit Period. | E. | Usual, Customary or Reasonable (UCR) |
6. | The individual or member who has the health plan coverage by virtue of being eligible on his or her own behalf rather than as a dependent. | F. | Subscriber |
7. | The administrative procedure used to process a claim for service according to the coverage. | G. | Adjudication |
8. | A term used to describe where the claim is during the claim payment process. | H. | Premium |
9. | A time period of one year, which is either a Calendar Year or other annual period, as shown in the Schedule of Benefits. Deductible often reset at this time. | I. | Creditable Coverage |
10. | The date the customer received the treatment. | J. | Benefit Period |
11. | A group of health care professionals contracted by a health care carrier to deliver medical services to its customers. | K. | Copay |
12. | Health or medical coverage under which a covered person was covered, prior to his/her enrollment date under this plan. | L. | Coordination of Benefits (COB) |
13. | The maximum dollar amount, as stated in the schedule of benefits, that any covered person or family will pay in any benefit period for covered services, treatments, or supplies. | M. | Deductible |
14. | A medical condition for which a member has received treatment during a specified period of time prior to becoming covered under a health plan (excluding pregnancy.) | N. | Out-of-Pocket Maximum |
15. | An organization that processes employee benefit claims for a separate entity. | O. | Pre-existing condition |
16. | Statement sent by the health plan explaining what medical treatments and/or services were paid. | P. | Provider Network |
17. | When a person is covered under more than one insurance or health plan. It requires that carriers coordinate with one another to correctly consider benefits for all services payable. | Q. | Claim Status |
18. | The amount paid to a health care professional for a service based on the typical charges for that service within a specific geographical area. | R. | Third Party Administrator |