A
Adverse Benefit Determination
An insurer's formal decision to deny, reduce, or end coverage for a service.
Affordable Care Act (ACA)
The 2010 federal law that created broad protections for health-plan members.
Allowed Amount
The maximum a plan will count toward a covered service.
Appeal
A formal request asking a plan to reconsider a denial.
B
Balance Billing
When a provider bills you for the gap between their charge and the allowed amount.
C
Claim Denial
A plan's refusal to pay for or authorize a service.
Clinical Guidelines
Evidence-based standards insurers use to judge whether care is appropriate.
COBRA Continuation Coverage
A right to keep employer coverage for a time after it would otherwise end.
Coinsurance
Your percentage share of the cost of a covered service.
Concurrent Review
A plan's ongoing review of care while you are still receiving it.
Continuity of Care
Protections that let you keep seeing a provider during a coverage transition.
Coordination of Benefits
Rules that decide which plan pays first when you have more than one.
Copayment
A fixed dollar amount you pay for a covered service.
E
ERISA
The federal law governing most employer-sponsored health plans.
Essential Health Benefits
A core set of ten service categories most plans must cover.
Evidence of Coverage (EOC)
The detailed contract describing exactly what your plan covers.
Exclusive Provider Organization (EPO)
A network-only plan that usually skips referrals but not the network.
Expedited Appeal
A faster appeal for situations where waiting could harm your health.
Experimental or Investigational
A common denial reason claiming a treatment is unproven.
Explanation of Benefits (EOB)
A statement showing how a claim was processed and what you owe.
External Review
An independent review of a denial by reviewers outside your plan.
F
Formulary
The list of prescription drugs a plan agrees to cover.
Formulary Tier
The pricing level a covered drug is placed in.
G
Gold Carding
Programs that exempt reliable providers from prior authorization.
Grievance
A formal complaint about service quality rather than a coverage decision.
H
Health Insurance Claim
A request for payment submitted to your plan for covered care.
Health Maintenance Organization (HMO)
A plan type built around a set network that usually requires referrals.
HIPAA
The federal law protecting the privacy of your health information.
I
In-Network
Providers who have a contract with your plan for lower rates.
Independent Review Organization (IRO)
The outside body that conducts external reviews of denials.
Internal Appeal
The first level of appeal, handled inside your plan.
L
Letter of Medical Necessity
A provider's written case explaining why care is needed.
Local Coverage Determination (LCD)
A regional Medicare rule on when a service is covered.
M
Medical Necessity
The standard of care being appropriate and needed for your condition.
Medical Policy
An insurer's internal rules for covering a specific treatment.
Medicare Advantage
Private plans that deliver Medicare benefits, often with prior auth.
N
National Coverage Determination (NCD)
A nationwide Medicare rule on whether a service is covered.
Non-Formulary Exception
A request to cover a drug that is not on the plan's list.
Non-Medical Switching (Forced Switch)
Being pushed off a working treatment for cost, not medical, reasons.
O
Off-Label Use
Using an approved drug for a purpose beyond its FDA labeling.
Out-of-Network
Providers without a contract with your plan, often costing more.
Out-of-Pocket Maximum
The yearly cap on what you pay before the plan covers 100%.
P
Peer-to-Peer Review
A direct call between your doctor and the plan's reviewing physician.
Point-of-Service Plan (POS)
A hybrid plan blending HMO referral rules with some out-of-network coverage.
Pre-Existing Condition
A health condition you had before coverage began.
Preferred Provider Organization (PPO)
A flexible plan type that covers out-of-network care at a higher cost.
Premium
The recurring amount you pay to keep coverage in force.
Prior Authorization
Advance approval a plan requires before it will cover a service.
R
Rescission
A retroactive cancellation of coverage as if it never existed.
Retrospective Review
A plan's review of care after it has already been provided.
S
Site-of-Service Review
A plan steering care to a lower-cost location.
Step Therapy (Fail-First)
A rule requiring you to try cheaper treatments before a preferred one.
Summary of Benefits and Coverage (SBC)
A short standardized snapshot of what a plan covers and costs.
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Disclaimer: These definitions are provided for general educational purposes only and are not legal, medical, or insurance advice. Insurance rules, deadlines, and terminology vary by plan, state, and over time. Always check your own plan documents and confirm current details before acting.