Medical Insurance: A-C

A

Administration - the business of process management, making sure all processes and systems are in place and effective to manage a product.

Allowed Amount - the highest set price for a particular service. The price is based on a provider's contracted rate, the network rate, or the area's reasonable and customary rates.

Assignment of Benefits - patients allowing payment for services rendered to be sent directly to the provider of service.

B

Behavioral Health - see Mental Health/Chemical Dependency

Benefits - what is specified as "covered" by the insurance administrator, or other services provided by the employer.

Benefits Administration - the process by which employers specify the policies they wish to purchase, what should be covered within that insurance policy, and manages the electronic filing of eligibility information to the insurance administrator.

Birthday Rule - an established process to assist in determining which parent's policy will pay first for treatment received by a dependent.

Brand Name Prescription - see Preferred Prescription.

Break in Coverage - if an individual loses medical coverage for longer than 63 days, then the individual may be subject to denial of coverage or pre-existing conditions limitations by a new insurance carrier.

Burden of Proof - necessary legal documentation to support an individual's claim for dependent coverage.

C

Claims - how reimbursement is requested.

COBRA, Consolidated Omnibus Budget Reconciliation Act - a guarantee of continued coverage in the event an individual is no longer employed with the company that has contracted to purchase medical coverage. The individual must make 100% payment of the monthly premiums.

Contracted Rate - the amount a provider agrees as payment for a particular service (also see Allowed Amount).

Codes - predetermined specific codes required to appear on claims in order to facilitate processing the claims.

Coinsurance - a percentage of the cost that must be paid by the policy holder for treatment.

Co-pay - a specified amount that must be paid by the policy holder at the time of treatment.

Coordination of Benefits - should an individual, or other members of a family, be covered by more than one policy, there is a process to determine which policy pays in what order for treatment received.

Coverage - a term used throughout the insurance industry to describe who is included by a policy, or what will be paid for by a particular policy.

Customer Service Representative - the individual who is trained to be able to assist callers with questions pertaining to, in this case, medical insurance.