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Insurance Examiner



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1 refers to providers or health care facilities that are part of a health planís network of providers with which it has negotiated a discount
6 The amount you or your employer pays in exchange for health insurance coverage
7 is a predetermined (flat) fee that an individual pays for health care services, in addition to what the insurance covers.
8 The date on which a healthcare service was provided
9 Dependent a person or persons relying on the policy holder for support may include the spouse and/or unmarried children (whether natural, adopted or step) of an insured
10 A primary care physician is a physician that would coordinate memberís treatments and the providers that the member utilizes by a referral system
11 an industry term used to describe an insurance company or HMO that provides life, health, or other insurance programs with a financial risk.
14 the maximum amount a health plan will pay in benefits to an insured individual during that individualís lifetime.
15 the maximum fee that a health plan will deem payable for a given service.
16 the insurance companyís written explanation regarding a claim, showing what they paid and what the client must pay. The document is sometimes accompanied by a benefits check.
17 when a member holds two or more separate health insurance policies, using order of benefit rules will allow the claims to process without exceeding 100% payment.
18 The geographic area in which a health plan is prepared to deliver health care through a contracted network of participating providers.
19 A predetermined limited amount of money that an individual must pay out before an insurance company or (self-insured employer) will pay 100 percent for an individualís health care expenses.
22 the amount commonly charged for a particular medical service by physicians within a particular geographic region
24 a medical condition that is excluded from coverage by an insurance company because the condition was believed to exist prior to the individual obtaining a policy from the particular insurance company.
26 Supplemental healthcare services such as laboratory work, x-rays or physical therapy that are provided in conjunction with medical or hospital care
31 When a state passes laws requiring that health insurance plans include specific benefits.
35 An individual (patient) who receives health care services (such as surgery) on an outpatient basis, meaning they do not stay overnight in a hospital or inpatient facility.
2 Insured health care costs for which one is responsible, because of the application of deductibles, coinsurance and co-payments
3 refers to money that an individual is required to pay for services, after a deductible has been paid. Coinsurance is often specified by a percentage.
4 a limit on the amount of benefits paid out for a particular covered expense, as disclosed on the Certificate of Insurance.
5 refers to the amount payable by the insurance company to a claimant, assignee, or beneficiary when the insured suffers a loss.
8 Medical equipment used in the course of treatment or home care, including such items as crutches, knee braces, wheelchairs, hospital beds, prostheses, etc..
12 The process through which a patient under a managed care health insurance plan is authorized by his or her primary care physician to a see a specialist for the diagnosis or treatment of a specific condition.
13 A bill for medical services rendered, typically submitted to the insurance company by a healthcare provider
20 Deductible the amount an individual must pay for health care expenses before insurance (or a self-insured company) covers the costs
21 An event that triggers coverage under the policy.
23 a provision within a health insurance policy that eliminates coverage for certain acts, property, types of damage or locations.
25 Systems and techniques used to help direct, manage the utilization, cost and quality of healthcare services to enhance the quality and cost-effectiveness of care
27 This is a requirement that an insured person calls their health insurance company and advises them a doctor has stated certain medical treatment is required. This is done before receiving treatment from the doctor or hospital
28 This phrase usually refers to physicians, hospitals or other health care providers who are considered nonparticipants in an insurance plan (usually an HMO or PPO)
29 The amount you could be responsible for (in addition to any co-payments, deductibles or coinsurance) if you use an out-of-network provider and the fee for a particular service exceeds the allowable charge for that service
30 a term used by insurance companies, case managers and/or employers to describe the amount of time an individual stays in a hospital or in-patient facility
32 The process used by health plans to determine the amount of payment for a claim.
33 Expenses defined by the health insurance plan as eligible for coverage.
34 the date a memberís insurance coverage commences
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