| A | B |
|---|
| Adjudicate | To review and determine how to process a medical claim as to whether to pay it, deny it or to request additional information [medical records, other insurance information (OI) or subrogation etc.] to accurately process it. |
| Allowed Amount | The maximum amount the insurance plan will pay for a covered service based on negotiations with providers (doctors, hospitals and other healthcare providers that are contracted with a specific health plan). |
| Auto-Adjudication | Automated process to evaluate how a medical claim processes and finalizes using computer-based logic and rules along with any predefined data based on provider network, pricing and how it applies to the health and welfare benefits without manual intervention which expedites the processing with accuracy. |
| Automated Clearing House (ACH) | A network which facilitates electronic transfers of funds between bank accounts. |
| Balance Billing | When a provider bills the patient for the remaining balance after the insurance plan has paid its portion. |
| Claim | A request for payment from a health insurance plan for covered healthcare services. |
| Deductible | The amount that must be met for an individual or group pays for covered services before the insurance plan starts paying. |
| Coinsurance | A percentage of the cost of covered services that the insured person pays after the deductible is met. |
| Copayment/Copay | A fixed amount paid by the insured person at the time of receiving a service, such as a doctor's visit. |
| Electronic Funds Transfer (EFT) | A digital method of moving money between bank accounts without using physical checks or cash. |
| Explanation of Benefits (EOB) | A document sent to a member of a health plan from a health insurance company that details the cost of medical services received from a provider and how it applied to the health and welfare benefits of the members’ health plan. |
| Explanation of Payment (EOP) | A document sent to a provider from a health insurance company that details how the services billed were processed against the provider network, pricing and the patient’s health and welfare benefits and how the provider was reimbursed. |
| Fully Insured | The employer pays a fixed premium to a health insurance company which assumes the risk of providing health and welfare coverage and paying the claims regardless of how much healthcare is used. |
| Joint Administrative Agreement (JAA) | An agreement between two or more entities work together to administer health and welfare benefits. |
| Out of Pocket Expenses | Deductibles, coinsurance and copayments for covered services to include services not covered by the health and welfare plan. |
| Out of Pocket Maximum (OOPM) | The limit a health and welfare participant will pay for covered healthcare services in a policy year. |
| Participating Medical Group (PMG) | A group of physicians that have agreed to participate in a health plan network. |
| Patient’s Responsibility | Portion of medical claim that a person is financially responsible for paying out of their pocket after the claim has been processed against their health and welfare benefit plan and the plan doesn’t cover. |
| Payor | Who is financially responsible for the reimbursement or paying of the claims i.e. health insurer or a self-funded client/group. |
| Premium | The amount an individual or group/client pays to maintain health insurance coverage. |
| Provider Network | A list of doctors, hospitals, and other healthcare providers that are contracted with a specific health plan. |
| Reimbursement | Compensation to providers for services. |
| Self-Insured [aka Administrative Services Only (ASO)] | A health plan that is a self-funded arrangement where an employer assumes the financial risk of providing health and welfare benefits to its employees. |
| Subrogation | Allows an insurance company a legal right to pursue a payment from a liable party after a participant has incurred an injury or loss after an accident if medical claims have been paid. |
| Summary of Benefits & Coverage (SBC) | A document that outlines the benefits, costs, and other important features of a health plan. |
| Taft-Hartley Act of 1947 | A US Federal Law that regulates labor unions and their relationship with employers. |
| Third Party Administrator | An external company that is under contract to provide administrative services, i.e. |
| Timely Filing | A deadline from the date of service to when a health and welfare claim is received for processing. |
| Turn Around Time (TAT) | The timeframe from when a claim is received to when it is processed and a payment is made. |
