Insurance Glossary

 

Assignment of Benefits - Your signed authorization to your medical provider, doctor or hospital, assigning the payment to be made directly to them for your medical treatment.

 

Business Day - Every working day that insurance companies are open for business, which excludes Saturday, Sunday, and holidays.

 

Calendar Day - Every day of the calendar month, which includes Saturday, Sunday, and holidays. However, if any action tied to a time frame in an insurance policy or CDI regulation or code falls on a Saturday, Sunday, or holiday, then that particular action is postponed to the next working day.

 

Certificate of Coverage - Ddocument issued to a member of a group health insurance plan illustrating evidence of participation in the insurance.

 

Certificate of Creditable Coverage - Written statement from your previous health insurance company or plan documenting the length of time you were covered.

 

Creditable Coverage or Prior Qualifying Coverage - The number of months you had health insurance in place before your new or current policy became effective. Creditable coverage must be counted towards any preexisting condition exclusion in individual or group policies.

 

Claim - Nnotification to your insurance company that payment is due under policy provisions.

 

Copayment - The amount of charges you pay to your provider for having covered health care services in addition to any deductible.

 

Coverage - The scope of protection provided by an insurance contract which includes any of the listed benefits in an insurance policy.

 

Denial - The insurance company decision to withhold a claim payment or preauthorization. A denial may be made because the medical service is not covered, not medically necessary, or experimental, or investigational.

 

Deductible - Fixed amount which is deducted from eligible expenses before benefits from the insurance company are payable.

 

ERISA - Stands for the Employee Retirement Income Security Act (1974). Administered by the U.S. Department of Labor, Employee Benefits Security Administration. ERISA regulates employer sponsored pension and insurance plans (self-insured plans) for employees.

Exclusions and/or Limitations - Conditions or circumstances spelled out in an insurance policy which limit or exclude coverage benefits. It is important to read all exclusion, limitation, and reduction clauses in your health insurance policy or certificate of coverage to determine which expenses are not covered.

 

Experimental and/or Investigational Medical Services - A drug, device, procedure, treatment plan, or other therapy which is currently not within the accepted standards of medical care.

 

Grace Period - A specified period immediately following the premium due date during which a payment can be made to continue a policy in force without interruption. This applies only to Life and Health policies. Check your policy to be sure that a grace period is offered and how many days, if any, are allowed.

 

Guaranteed Issue - A health insurance policy that must be issued regardless of any preexisting medical condition. The present and past physical condition of a health insurance applicant is not considered as a part of underwriting. No physical examination is required. The insurance company cannot decline coverage to an applicant of a guaranteed issue policy based on medical history.

 

Independent Medical Review - A process where expert medical professionals who have no relationship to your health insurance company or health plan review specific medical decisions made by the insurance company. California law provides for an Independent Medical Review Program, which is administered by the CDI and the DMHC depending upon what type of coverage you have (indemnity or HMO).

 

Medically Necessary - A drug, device, procedure, treatment plan, or other therapy that is covered under your health insurance policy and that your doctor, hospital, or provider has determined essential for your medical well-being, specific illness, or underlying condition.

 

Policy - The written contract between an individual or group policyholder and an insurance company. The policy outlines the duties, obligations, and responsibilities of both the policyholder and the insurance company. A policy may include any application, endorsement, certificate, or any other document that can describe, limit, or exclude coverage benefits under the policy.

 

Preexisting Condition - Any illness or health condition for which you have received medical advice or treatment during the six months prior to obtaining health insurance. Group healthcare policies cover preexisting conditions after you have been insured for 6 months, and individual policies cover preexisting conditions after you have been insured for 1 year. Reference CIC Section 10198.7. Creditable coverage must be counted towards any preexisting condition exclusion in either an individual or group policy.

 

Usual, Reasonable, and Customary - The amount that your insurance company determines is the normal payment range for a specific medical procedure performed within a given geographic area. If the charges you submit to your health insurance company are higher than what is considered normal for the covered health care services, then your health insurance company may not allow the full amount charged to you.