Glossary of Terms

Glossary of Terms




Allowed Amount

Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance” or “negotiated rate”. If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.)

Appeal

A request for your health insurer or plan to review a decision or a grievance again.

Balance Billing

When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.

Coinsurance

Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.

Complications of Pregnancy

Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency caesarean section are not complications of pregnancy.

Copayment

A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.

Current Procedural Terminology (CPT) Code

The CPT code is set by the American Medical Association to describe medical, surgical and diagnostic services in a uniform manner for physicians, patients and plans.

Deductible

The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.

Diagnostic Medical Care

Diagnostic medical care is care received when you visit your doctor for treatment of specific symptoms or conditions.

Durable Medical Equipment (DME)

Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.

Emergency Medical Condition

An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.

Emergency Medical Transportation

Ambulance services for an emergency medical condition.

Emergency Room Care

Emergency services you get in an emergency room.

Emergency Services

Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.

Excluded Services

Health care services that your health insurance or plan doesn’t pay for or cover.

Explanation of Benefits (EOB)

You will receive an EOB by mail after Independent Health processes a claim for a medical service. This document lists the billed charges for the services rendered, the Independent Health allowed amount for the service, and the amount, if any, applied to the deductible requirement. Note: Your physician’s office will bill you separately if you owe anything.

Explanation of Reimbursement (EOR)

An EOR is a summary of claims that Independent Health has processed through your FSA/HRA account. It indicates the dollar amounts you are being reimbursed for. You will receive an EOR with your reimbursement check.

Flexible Spending Account (FSA)

An FSA is an account offered through your employer that allows you to set aside pre-tax dollars from your paycheck to help you pay for eligible medical expenses. Eligible expenses include over-the-counter medicines, prescriptions and copays. If you participate in Independent Health’s FSA, you will receive your enrollment and member information separate from your health plan information. If you are enrolled in our FSA and have questions, please call our Reimbursement Department at (716) 504-1468.

Grievance

A complaint that you communicate to your health insurer or plan.

Habilitation Services

Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

Health Insurance

A contract that requires your health insurer to pay for some or all of your health care costs in exchange for a premium.

Health Reimbursement Arrangement (HRA)

An HRA is a pre-tax account used to pay for eligible medical expenses. Typically, HRAs are designed to complement or supplement your health plan. Your employer or group determines what medical expenses are eligible. An HRA is funded by your employer. If your employer has chosen to offer Independent Health’s HRA, you will receive your enrollment and member information separate from your health plan information. If you enrolled in our HRA and have questions, please call our Reimbursement Department at (716) 504-1468.

Health Savings Account (HSA)

An HSA is an account for individuals covered by a qualified high-deductible health plan. The account can be funded by you, your employer or both. A bank will administer your HSA directly and provide you with the materials to manage your account most effectively. The bank also serves as “trustee” or “custodian” of your accounts. Funds in the HSA can be used to pay for qualified medical expenses. Any unused dollars grow tax-free, carry over year-to-year, and move with you from job to job. Unused dollars earn interest or can be invested, similar to a 401k plan, in the investment funds available through the bank that manages your HSA.

Home Health Care

Health care services a person receives at home.

Hospice Services

Services to provide comfort and support for persons in the last stages of a terminal illness and their families.

Hospitalization

Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.

Hospital Outpatient Care

Care in a hospital that usually doesn’t require an overnight stay.

In-network Coinsurance

The percentage (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network coinsurance usually costs you less than out-of-network coinsurance.

In-network Copayment

A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network copayments usually are less than out-of-network copayments.

In-Network Coverage

In-network refers to the network of physicians and providers that participate with Independent Health. If you choose to access services in network, you will receive Independent Health’s negotiated rates with those providers. Participating providers are listed in the Find a Doctor tool.

Inpatient Hospitalization

This status applies when a patient is admitted to a hospital or clinic for treatment that requires at least one overnight stay. Your physician will determine if you need to be hospitalized. You will need to cover the cost for the plan’s applicable deductible, any applicable copayment or coinsurance, any additional payments if you go to a non-participating facility, and any personal convenience items and plan exclusions. Inpatient hospitalization requires precertification.

Medically Necessary

Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

Negotiated Contract Rate

Also referred to as “fee schedule reimbursement” or “allowed amount,” this is the amount a provider contractually agrees to charge an Independent Health member for a service.

Network

The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.

Non-Preferred Provider

A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.

Out-of-network Coinsurance

The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.

Out-of-Network Copayment

A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments.

Out-of-Network Coverage

If you visit a non-participating physician or hospital, your service is subject to your deductible, plus any copayment and/or coinsurance and balance billing.

Out-of-Pocket Maximum

The out-of-pocket maximum is the dollar limit for deductibles, copayments and coinsurance amounts that you are responsible for in a given time period. Once you reach your out-of-pocket maximum, all services are covered in full. To find out what your out-of-pocket maximum is, check your Benefit Summary or Contract (“Certificate of Coverage”). Additional Payment to a non-participating provider (balance billing) does not count against the out-of-pocket maximum.

Physician Services

Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.

Plan

A benefit your employer, union or other group sponsor provides to you to pay for your health care services.

Preauthorization

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug, or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.

Precertification

Some services and procedures will require approval from Independent Health before you proceed, to ensure that you are receiving safe, appropriate care. This is known as precertification. Before you receive care that requires precertification, call our Member Services Department at (716) 631-8701 or 1-800-501-3439. Please see your Contract (“Certificate of Coverage”) to view a complete listing of services requiring precertification.

Preferred Provider

A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.

Premium

The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.

Prescription Drug Coverage

Health insurance or plan that helps pay for prescription drugs and medications.

Prescription Drugs

Drugs and medications that by law require a prescription.

Preventive Care Services*

Preventive care services focus on the prevention, early detection and early treatment of conditions, generally including routine physical exams, immunizations and well-visits. The emphasis is on maintaining good health. For a listing of covered preventive care services under your plan, please see your Benefit Summary or Contract (“Certificate of Coverage”).

Independent Health covers  preventive care services in full when rendered by a participating provider/health care practitioner. There may be other services performed in conjunction with the preventive care services. You may be responsible for any additional copayment or coinsurance according to your contract.

*Does not include procedures, injections, diagnostic services, laboratory and X-ray services, and any other service not billed as an Evaluations and Management code (E&M code) as preventive.

Primary Care Physician

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.

Primary Care Provider

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.

Provider

A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.

Rehabilitation Services

Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

Remaining Deductible Responsibility

This is the amount of out-of-pocket medical expenses that you must pay to satisfy your deductible requirement. Once you meet your deductible, you are then responsible only to pay the applicable charge for covered services (i.e., copayments, coinsurance, additional payments, etc.) as defined in your Contract (“Certificate of Coverage”).

Skilled Nursing Care

Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.

Specialist

A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care.

UCR (Usual, Customary and Reasonable)

The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.

Urgent Care

Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. View a list of participating urgent care facilities.

View and print Glossary of Summary of Benefits & Coverage.