Glossary of Terms ~ZT from hospital website
For your convenience, we've included a glossary of health insurance terms that have been used here and/or may be used in discussions you may have with your plan's customer service representatives.
Authorization Written approval from your insurance carrier to receive medical care at xxx Hospital. Please note that a new authorization is needed for each type of service, such as chemotherapy, radiation therapy, MRIs, CT scans, outpatient surgery, and each admission.
Carrier An insurance company that issues policies and makes payments to medical providers for its members.
Case Manager A xxx Hospital employee, usually a nurse, who will advocate for you on behalf of your insurance company if your proposed treatment plan is not available within your network of providers.
Co-Insurance The amount (usually a percentage) of the healthcare costs for which you have to pay. You pay co-insurance even if your deductible has been met. For example, you may pay 20 percent of the cost of medical services after meeting the deductible.
Co-Payment A flat fee that you pay for healthcare services from an in-network provider for certain services such as an office visit or physical therapy. For example, you may be responsible for a $10 "co-payment" for each office visit.
Deductible The annual amount you must pay for healthcare expenses before your insurance company begins to pay for covered
Exclusive Provider Organization (EPO) A managed care organization that is similar to a preferred provider organization (PPO). If you're a member of an EPO, you can see any doctor in the network without obtaining a referral. You do not need to choose a primary care physician, but cannot go to an out-of-network provider without an authorization. You are responsible for all charges if you receive treatment from a non-network provider and do not have an authorization.
Financial Counselor xxx Hospital employee who is available to answer questions you may have or to explain billing procedures.
Health Maintenance Organization (HMO) A managed care plan that requires its members to use the services of their network of physicians, hospitals, or other healthcare providers. If you're a member of an HMO, you are required to choose a primary care physician who must provide you with a referral to see a specialist.
Indemnity Health Plans Also called a fee-for-service plan. An insurance plan that allows you to see medical providers of your choice. You are responsible for paying a percentage of total charges no matter which medical provider you see.
In-Network Physicians, hospitals, or other healthcare providers who have a managed care contract with your insurance plan. The fees of these providers are covered by the plan. You may still be responsible for a co-payment.
Managed Care An insurance plan that contracts with a network of healthcare providers. Your financial responsibility is significantly less when provided in-network. EPOs, HMOs, POS, and PPOs are managed care plans.
Medicaid A program that provides medical benefits to eligible people who have a low income level and people with disabilities needing healthcare. The federal and state governments share the program costs.
Medicare A federal health insurance program that covers the cost of hospitalization, medical care, and some related services for people 65 years or older and for people with disabilities.
Network A group of physicians, specialists, hospitals, outpatient centers, pharmacies, and other providers who are contracted with an insurance company to provide healthcare services to their subscribers.
Non-Covered Procedure or Service A medical procedure or service that an insurance plan considers medically unnecessary (or experimental) and therefore does not cover.
Out-of-Pocket Costs The amount you are responsible to pay for medical services, which are not reimbursed by your insurance plan.
Out-of-Network Physicians, hospitals, or other healthcare providers who do not have a managed care contract with an individual's insurance company. When you receive care "out-of-network," you will be financially responsible for that care Point of Service (POS) An HMO plan that also includes an indemnity plan option. You can decide whether to go to a network provider for lower out-of-pocket costs, or go to an out-of-network provider with higher out-of-pocket costs.
Pre-Certification Obtaining authorization from your insurance plan for any hospital admission and those outpatient procedures specified under your policy.
Preferred Provider Organization (PPO) A health plan that contracts with a group of providers to offer medical services at discounted rates. Typically you can see any doctor in the PPO network without requiring special approval, and you usually do not need to choose a primary care physician. PPOs allow you to seek care outside of the PPO network; however, the benefits are usually reduced, and the insured party has a greater out-of-pocket expense.
Primary Care Physician (PCP) A general or family practitioner who is your personal physician and first contact within a managed care system. The PCP will usually direct the course of your treatment and refer you to other doctors and/or specialists in the network if specialized care is needed.
Provider Any medical professional (physician, nurse practitioner, etc.) or institution (hospital, clinic, etc.) that provides medical care.
Referral The approval form you receive from your primary care physician for you to see a specialist or get certain services. In many managed care plans, you need to get a referral form or slip before you get care from anyone except your primary care doctor. If you do not first get a referral, the plan may not pay for your care.
Usual, Customary & Reasonable (UCR), or Reasonable & Customary Every insurance carrier has a payment rate for each test, procedure, and medical service. The rates are what the insurer has decided are appropriate for these services in xxx. Health plans have different methods to determine what is usual and customary. xxx Hospital’s charges may be different from an insurer's rates due to the complexity of treatment, as well as the high level of care provided to our patients. If you have out-of-network benefits, you are responsible for paying the difference between xxx Hospital’s charges and the carrier's usual and customary allowances in addition to their co-insurance and deductible costs.
