Office of Human Resources - Benefits

Glossary of Terms

A - D | E - I | N- R

A - D  
Actively at work Plan provision that requires the employee to be performing the duties of the occupation where the employee normally works for coverage to commence. If the employee is absent due to illness or injury, the coverage does not commence until the employee returns. This rule does not include adding newborn to health insurance (such as an employee on maternity leave) nor does it extend to absences for annual leave provided the employee was not ill on the last scheduled day before annual leave.
Allowed Fees Term used by some dental plans for their participating dentist fees and/or maximum payable for a non-participating dentist.
Balance Billing Non-participating provider practice of billing the patient for any difference between the provider's billed charges and the patient's insurance plan maximum allowance (indemnity or PPO).
Billed Charge The amount the provider bills for services rendered.
Co-insurance The division of the allowed amount to be paid by the insurance company and the patient, i.e., 80/20 or 90/10. (The first percentage is paid by the company, the second by the employee)
Co-payment The fixed fee that must be paid to the provider at the time service is provided.
Deductible
return to top		 The initial amount the patient must pay out-of-pocket for covered services before benefits are payable by the insurance carrier in indemnity and PPO plans.
E - I  
Emergency Defined by each plan in accordance with their standard definitions.
Exclusive Provider Organization (EPO) A medical plan providing comprehensive medical benefits, including preventative care, using a select group of network providers.
Indemnity Plan A medical or dental plan which allows you to choose any licensed provider to receive care. Members are reimbursed for eligible medical or dental expenses according to the benefit schedule in effect, including deductibles and coinsurance.
In-Network
return to top		 Services provided by a contracted provider in accordance with all plan requirements.
N - R  
Non-participating Provider A provider with no contractual limitation on what he may bill and thus may practice balance-billing, as well as require payment at the time services are rendered.
Preferred Provider A provider who has signed an agreement with the insurance carrier not to charge more than the insurer's allowed fees.
Precertification Review process that verifies the medical necessity and appropriateness of proposed services or supplies.
Pre-existing Condition A condition diagnosed and/or treated prior to the effective date of your coverage or for which a prudent person would have been treated.
Preferred Provider Organization
(PPO) Plan		 A plan that provides benefits in an indemnity fashion, but pays a higher percentage of the cost of services if patients use a PPO-network provider than if they use non-PPO providers.
Rehabilitation Usually physical therapy, speech therapy and/or occupational therapy.