General Glossary Terms
Here you'll find definitions of basic terms used throughout this site. If you are unable to find an answer to your question, please visit our Frequently Asked Questions section, or contact us directly.
Ambulatory Care: A general term for care that doesn't involve admission to an inpatient hospital bed. Visits to a doctor's office are a type of ambulatory care.
Ambulatory Surgery: Surgical procedures performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called Outpatient Surgery.
Ancillary Care: Diagnostic and/or supportive services such as radiology, physical therapy, pharmacy or laboratory work.
Beneficiary: A person who is eligible to receive benefits under a health benefits plan. Sometimes "beneficiary" is used for eligible dependents enrolled under a benefits plan; "beneficiary" can also be used to mean any person eligible for benefits, including both employees and eligible dependents.
Benefit Year: The coverage period, usually 12 months long, which is used for administration of a health benefits plan.
Benefits: The portion of the costs of covered services paid by a health plan. For example, if a plan pays the remainder of a doctor's bill after an office visit copayment has been made, the amount the plan pays is the "benefit." Or, if the plan pays 80% of the reasonable and customary cost of covered services, that 80% payment is the "benefit."
Benefits Package: A term informally used to refer to the employer's benefits plan or to the benefits plan options from which the employee can choose. "Benefits package" highlights the fact a health benefits plan is a compilation of specific benefits.
Carrier: A term historically used for licensed insurance companies, although now is sometimes used to include both licensed insurers and HMOs.
Case Management: Coordination of services to help meet a patient's health care needs, usually when the patient has a condition which requires multiple services from multiple providers. This term is also used to refer to coordination of care during and after a hospital stay.
Claim: A claim is a request for payment under the terms of a health benefits plan.
Claim Status: Claims are Paid, Pended, Denied, or Received-Not-Yet-Processed.
Coordination of Benefits: A provision in a contract that applies when a person is covered under more than one group health benefits program. It requires that payment of benefits be coordinated by all programs to eliminate overinsurance or duplication of benefits.
Copayment (copay): What the participant pays at the time of service. Copayments are predetermined fees for physician office visits, prescriptions or hospital services.
Coverage: The benefits that are provided according to the terms of a participant's specific health benefits plan.
Deductible: The money an individual or family must pay from their own funds toward covered medical expenses, usually based on a calendar year. For example, if a plan has a $100 deductible, the deductible is met once the first $100 of the covered medical expenses for that year have been paid. After that, the plan begins to pay toward the cost of covered health care services.
Dependent: A person eligible for coverage under an employee benefits plan because of that person's relationship to an employee. Spouses, children and adopted children are often eligible for dependent coverage.
Diagnostic Tests: Tests and procedures ordered by a physician to help diagnose or monitor a patient's condition or disease. Diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory and pathology services or tests.
Discharge Planning: Identifying a patient's health care needs after discharge from inpatient care.
Disenrollment: Voluntarily terminating one's participation in a health benefits plan
Effective Date: The date on which coverage under a health benefits plan begins.
Eligible: Provisions contained in each health benefits plan that specify who qualifies for coverage under that plan.
Enrollee: An individual who is enrolled and eligible for coverage under a health plan contract. Also called Member.
Exclusions: Specific conditions or services that are not covered under the benefit agreement.
Explanation of Benefits (EOB): A statement provided by the health benefits administrator that explains the benefits provided, the allowable reimbursement amounts, any deductibles, coinsurance or other adjustments taken and the net amount paid. A participant typically receives an explanation of benefits with a claim reimbursement check or as confirmation that a claim has been paid directly to the provider.
Open Enrollment: A period when eligible persons can enroll in a health benefits plan.
Participant: A person who is eligible to receive health benefits under a health benefits plan. This term may refer to the employee, spouse or other dependents.
Participant ID: The unique identifier associated with a participant.
Precertification: The process of obtaining certification from the health plan for routine hospital stays or outpatient procedures. The process involves reviewing criteria for benefit coverage determination.
Pre-Existing Condition: A health condition (other than a pregnancy) or medical problem that was diagnosed or treated before enrollment in a new health plan or insurance policy.
Prescription Drug: A drug that has been approved by the Federal Food and Drug Administration which can only be dispensed according to physician's prescription order.
Preventive Care: Medical and dental services aimed at early detection and intervention.