Day an insurance policy ends. It can be a scheduled date, such as the end of a one-year. In addition, it may also be unscheduled in the event one party no longer wants coverage or if the insured is no longer eligible.
Termination Date
Formal review of a patient’s requested medical care compared to their insurance’s medical and reimbursement policies (MGMA). The aim is to determine if the intended care meets medical necessity requirements.
Pre-determination
The monthly fee you pay to keep your health insurance policy active.
Premium
The determination that a medical treatment or service is necessary to diagnose or treat a medical condition.
Medical Necessity
The amount of money you must pay out of pocket before your insurance starts to cover the costs of your care.
Deductible
A fixed fee you pay for each doctor's visit or prescription.
Copay
A type of funding arrangement that are subject to state insurance regulations, whereas self-insured health plans are not – they’re regulated at the federal level instead, under ERISA.
Fully-insured
A type of health insurance plan that allows you to choose any doctor or hospital, but you may pay more for out-of-network care.
Preferred Provider Organization (PPO)
A recommendation from your doctor to see another doctor or specialist.
Referral
The maximum amount of money you will have to pay out of pocket for your care in a calendar year/plan year.
Out-of-pocket maximum
A process that insurance companies use to determine whether a patient is eligible to receive certain procedures, medications, or tests, except in an emergency.
Pre-authorization
A doctor or hospital that has contracted with your insurance company to provide care at a discounted rate.
In-network provider
A percentage of the cost of your care that you pay after you have met your deductible.
Coinsurance
A doctor or hospital that has not contracted with your insurance company and may charge you more for care.
Out-of-network provider
A type of funding arrangement offered by an employer or association in which the employer (or association) takes on the risk involved with providing coverage, instead of purchasing coverage from an insurance company.
Self-insured
A type of health insurance plan that combines features of HMO and PPO plans.
Point-of-Service (POS)
The process of determining which of your insurance plans will pay for your care when you have multiple insurance policies.
Coordination of Benefits
The date your insurance coverage commences. In most cases, this will always be the first of a future month, although a newborn baby or newly adopted child can have coverage retroactive to the date of birth or adoption.
Effective Date
A cap on the total lifetime benefits you may get from your insurance company.
Lifetime Maximum
A type of health insurance plan that requires you to choose a primary care doctor who coordinates your care and refers you to specialists within the HMO network.
Health Maintenance Organization (HMO)