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Glossary of Insurance Terminology

  • Adverse determination or adverse decision – notice from your health insurance company that your appeal has been denied

  • Appeal – a written request to a health insurance company asking them to reconsider their decision to deny coverage or payment for a specific procedure or service

  • Bronchial Thermoplasty – also called “BT” is an out-patient procedure done by pulmonologists using thermal energy to reduce excessive smooth muscle in the lungs which  decreases the ability of the airways to constrict and therefore reducing the frequency of asthma attacks 

  • Centers for Medicare & Medicaid Services (CMS) – the federal government agency which runs two public health insurance programs called Medicare and Medicaid 

  • Class III medical devices - are devices that support or sustain human life, are of substantial importance in preventing impairment of human health, or which present a potential, unreasonable risk of illness or injury 

  • Controller medicines – medicine taken daily for long-term control of asthma 

  • Co-payment – a fee that you pay for health care services (like an office visit), in addition to what the insurance covers 

  • Coverage criteria - specific criteria that need to be met in order for an insurance company to pay for a service or procedure. 

  • Coverage policies - policies that describe if an insurance company will pay for a service or procedure. 

  • Deductible – the amount an individual must pay for health care costs before the insurance company pays for health care costs 

  • Diagnosis – the identification of a possible disease or disorder using physical signs, symptoms, health history, laboratory test results, and procedures 

  • External appeal – a written request to a review group outside the insurance company within your state asking them to review the insurance company’s decision(s) to deny coverage or payment for a specific procedure or service 

  • External appeals review board – usually an independent panel outside of an insurance company within the state that is selected to objectively review insurance company decisions to deny patient appeals for coverage or payment of a specific procedure or service 

  • External financing – payment options available from companies outside of the hospital or health care system to pay for health care procedures or services not covered by health insurance 

  • Fee-For-Service Indemnity Health Plan (FFS) - In traditional FFS plans, the patient has the freedom to choose any provider or facility.  The health plan pays for all or part of the cost of the plan based on the contract.  Traditional Medicare and Medicaid are FFS plans. 

  • Financing programs – program choices for paying for health care procedures or services not covered by health insurance 

  • Fully-funded plans – You or your employer purchase a private insurance plan from an insurance company and the insurance company pays the doctor and hospital for health care services.  The patient may have to pay a co-payment or deductible.

  • Gatekeeper - A primary-care provider (usually a doctor), who coordinates patient care and provides approval to use specialists, hospitals, laboratories, and other medical services. Approval is required by the gatekeeper for any services to be paid by the insurance company.  

  • Health Maintenance Organization Health Plan (HMO) – In an HMO, the patient must choose a provider and facility in a predetermined "network" for the health plan to pay all or part of costs.  Access to specialists is through a "gatekeeper" primary care doctor. If the patient goes out of network or does not go through the gatekeeper, he or she is responsible for all of the costs. 

  • High Deductible Health Plan (HDHP) - A HDHP can allow for only in-network coverage, similar to an HMO, or allow for out-of-network coverage, similar to a POS or PPO plan. The patient must spend a specified amount (the deductible) before coverage begins. 

  • In-house financing - payment options available from the hospital or health care system to pay for health care procedures or services not covered by health insurance 

  • In-network  – using healthcare providers or healthcare facilities within the network selected by your insurance company 

  • Insurance commissioner – the individual who works for your state department of insurance to regulate and the insurance industry in your state and protect consumers by enforcing insurance laws 

  • Investigational – a new medicine or procedure that is not approved for general use but is under investigation in clinical trials to confirm its safety and effectiveness 

  • Medicaid – public health insurance for individuals and families that meet low income requirements or with certain disabilities paid for by both the federal and state governments 

  • Medicare – public health insurance for Americans age 65 and older and younger people with disabilities paid for by the federal government

  • National Association of Insurance Commissioners –  an organization created and governed by the chief insurance regulators from the 50 states, the District of Columbia and five U.S. territories to create U.S. insurance standards and provide regulatory oversight and support to its members

     
  • Network – a group of healthcare providers and healthcare facilities selected by your  insurance company for you to use if you want your insurance company to pay all or part of the costs for covered services or procedures 

  • Oral corticosteroids – available in pill, tablet, or liquid form and used as short-term treatment for severe asthma episodes or as long-term therapy for some people with severe asthma. These are not the same medicines as anabolic steroids, which some athletes take illegally to build muscles.  

  • Out-of-network  – using healthcare providers or healthcare facilities outside of the network of selected healthcare providers or healthcare facilities by your insurance company 

  • Payment rates - amount an insurance company will pay a doctor and hospital for a service or procedure. 

  • peer-reviewed clinical articles – scientific research articles published in journals managed by doctors or other healthcare providers in the same medical field or specialty 

  • Point of Service Health Plan (POS) – Like an HMO, POS plans have a network and a "gatekeeper" primary care doctor.  However, if the "gatekeeper" doctor makes referrals out of network, the plan will pay some of the cost and the patient is responsible for the rest. 

  • Pre-authorization of benefits – is the process that allows doctors and other healthcare providers to determine if the patient is eligible for coverage for a proposed service or procedure (including specialists and /or non-emergency healthcare). This process is a requirement under a health plan, but it does not guarantee reimbursement. 

  • Pre-determination of benefits - is similar to pre-authorization in that it allows services and procedures to be reviewed for medical necessity. Benefit coverage is pre-determined before services are rendered and any limitation under a plan may be addressed before the service or procedure. This process is a courtesy and does not guarantee reimbursement. 

  • Pre-determination request – a request for the pre-determination of benefits 

  • Pre-determination request appeal - a doctor or other healthcare provider’s written request to a health insurance company asking them to reconsider their decision to deny coverage or payment for a specific procedure or service as medically necessary 

  • Preferred Provider Organization Health Plan (PPO) – Is like a POS plan but without the necessary referrals for payment from the plan. 

  • Primary care doctor – the doctor who coordinates all of a patient’s health care

  •  Private health plans - are health plans run by commercial insurance companies such as Aetna, Blue Cross Blue Shield, United Healthcare, and many others

  • Public health insurance – are health plans run by the federal and state governments which are Medicare and Medicaid

  • Self-funded plans – The employer hires an insurance company to administer this private health insurance plan.  The employer (typically a large employer) pays the providers for health care services.  The patient may have to pay a co-payment or deductible.­­­­­­­­­­­­­­­­­­­­­

  • Severe persistent asthma – asthma that is difficult to control because it does not respond to the medicines for long-term asthma treatment and patients experience severe asthma symptoms regularly

  • State Department of Insurance – where the state insurance commissioner works to regulate the insurance industry in your state and protect consumers by enforcing insurance laws

 

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www.aafa.org 1-800-7-ASTHMA