Healthcare Terminology Made Simple
These definitions apply in most cases. Some healthcare plans may use some terms differently. Please check to see how your plan defines terms.
Board Certified - a term used to describe a physician who has passed an examination given by a medical specialty board and who has been certified as a specialist in that medical area.
Claim - information submitted by you, your doctor or the hospital to document the medical services you or your family member received. This information is used to process payment to you or the healthcare provider.
Co-Insurance - the amount you must pay for the healthcare services you or your family member receive. This is usually defined in a percentage amount. Often, co-insurance applies after first meeting a deductible requirement.
Coordination of Benefits - a provision that applies if you are covered under more than one healthcare plan. It requires that payment of benefits be coordinated by the plans to eliminate duplication of benefits.
Co-Payment (Co-pay) - a cost-sharing arrangement in which you pay a fixed amount for a specific service, such as $10 for an office visit. You are usually responsible for payment at the time the healthcare is rendered.
Deductible - the amount you must pay each year from before the health plan will pay for your healthcare expenses.
Employee Contribution - the amount you must contribute toward the costs of your insurance. This is usually paid monthly through payroll deduction.
Explanation of Benefits (EOB) - the statement sent to you by your health plan outlining the services you received, how much is paid to the provider(s), and how much you are responsible for paying.
Gatekeeper - a term used to describe a physician who serves as your primary contact for coordinating your medical care and referrals. This is usually a family practitioner, general internal medicine doctor, or pediatrician.
Payer - a public or private organization that pays for or underwrites coverage for healthcare expenses.
Pre-Authorization - this is another term for pre-certification which is the process of obtaining approval for a service or medication. Without this, the service or medication is not covered.
Pre-Certification - this is when you or your healthcare provider review your planned medical care with your insurance company. This helps clarify your benefits and what the insurance company will pay for.
Pre-Existing Condition - any medical condition that has been diagnosed or treated within a specified period immediately before the effective date of your coverage.
Preferred Providers - physicians, hospitals and other healthcare providers who contract to provide health services to persons covered by a particular health plan.
Premium - another term to refer to your employee contribution plus whatever your employer pays for the coverage.
Preventive Care - comprehensive care focusing on prevention, early detection and early treatment of conditions, generally including routine physical examination, immunization and well-person care.
Primary Care Physician - a physician whose practice is devoted to general internal medicine, family/general practice and pediatrics. Some plans may consider an obstetrician/gynecologist as a primary care physician.
Utilization Review - a formal review of the appropriateness of healthcare services before, during or after care is received.