Glossary

The final amount on a claim that is subjected to deductible, coinsurance, and non-covered or ineligible charges. This is calculated by starting with the Billed Charges and subtracting the Discount on the claim.

This term has 2 connotations in the industry, one of which is a high-level term for any written or verbal attempt to obtain further information or contest a determination made by the plan, and a second term that has a more formal meaning, suggesting that a written or verbal challenge was submitted in order to request a change in benefit status or determination, and sometimes originating from a state department of insurance.

The practice of a medical provider billing a patient for applicable deductible, coinsurance, non-covered, ineligible, or other charges.

The amount a given provider charges on the claim form or other invoice submitted to a member or an assigned benefits administrator. This amount is correlated to the Chargemaster created by the provider.

The master list of charges created by a provider based on the type of procedure, complexity, or other criteria.

The amount that is deducted from the Billed Charge before calculating the plan memberʼs deductible, coinsurance, or non-covered charges.

A benefit level determination where a claim is applied to the in-network deductible and/or coinsurance as established by the plan.

The acronym for Medicare-based Pricing.

Similar to RBP or Reference–based Pricing, this term more specifically refers to the use of Medicare when calculating a claimʼs allowed amount.

A set of providers that is more limited in scope, such as being affiliated to one local hospital or healthcare system, or perhaps being more geographically distributed but having been contracted with on a more limited basis. In either case, this model avoids a widespread Network typically having a significantly larger collection of providers. Also referred to as a direct, or high-value network.

Any collection of providers that have a contractual relationship with the health plan, whether directly created by the health plan or leased by the plan. Not all Network providers are allowed on an In-Network benefit level, depending upon the type of Network.

The acronym for Out-of-network providers.

A benefit level determination where a claim is applied to the out-of-network deductible and/or coinsurance as established by the plan.

This term describes any provider that is not in the PRIMARY PPO that a member accesses under the health plan. This is typically associated to a Network logo on the front of the memberʼs ID card.

A provider that charges above a given level for its medical services; for example, a provider with billed charges at or above 1,000% of Medicare (10 times the amount that would be allowed by Medicare) could be considered to be an Outlier Provider.

Preferred Provider Organization, or a set of providers that are made available for a member to access on an in-network basis.

The highest level or main Network associated with the memberʼs health plan. In some cases, a member may have access to multiple Networks, usually indicated with Network logos on the ID card. The Primary PPO is the focal point for searching for a provider that participates with the health plan.

The acronym for Reference-Based Pricing.

This term has 2 connotations in the industry, one of which is a high-level term for using a reference point (or benchmark) to reimburse medical providers, and a second term that has been used to mean that a health plan does not use a PPO network and reimburses all providers at a reference point (or benchmark). The key difference here is that the high-level term encompasses additional programs such as pricing claims for contracted providers and for out-of-network providers.