一种
一种mbulatory care医生办公室或外科中心没有过夜的卧床护理。
一种uthorization授权是保险公司或健康计划的批准，例如住院。您的保险公司或健康计划可能需要预授权，或者您被录取或非HMO提供者对待您。
b
balance billingbalance billing is the practice of a provider billing you for all charges not paid by your insurance plan, even if those charges are above the plan’s usual, customary and reasonable (UCR) charges or are considered medically unnecessary. Managed care plans and service plans generally prohibit providers from balance billing except for allowed copayments, coinsurance and deductibles. Such prohibition against balance billing may even extend to the plan’s failure to pay at all (for example, because of bankruptcy).
benefit Amountpayable by the insurance company to a claimant, assignee, or beneficiary when the insured suffers a loss.
C
载体保险公司或HMO提供健康计划。
Certificate of Insurancethe printed description of the benefits and coverage provisions forming the contract between the carrier and the customer. Discloses what it covered, what is not, and dollar limits.
Claim个人（或其提供者）向个人保险公司的要求，要求保险公司为从医疗保健专业人员那里获得的服务付费。
Claims reviewClaims review is the review your insurer or health plan performs before paying your doctor or reimbursing you. This review allows the insurer to validate the medical appropriateness of the services given and review the charges related to your care.
Co-InsuranceCo-insurance refers to money that an individual is required to pay for services, after a deductible has been paid. Co-insurance is often specified by a percentage. For example, the employee pays 20 percent toward the charges for a service and the employer or insurance company pays 80 percent.
共同付款Co-payment is a predetermined (flat) fee that an individual pays for health care services, in addition to what the insurance covers. For example, some HMOs require a $10 "co-payment" for each office visit, regardless of the type or level of services provided during the visit. Co-payments are not usually specified by percentages.
Coordination of benefits (COB)Coordination of benefits is an agreement between your insurers to prevent double payment of your care when more than one plan provides coverage. The agreement determines which insurer has primary responsibility for payment and which has secondary responsibility. These rules are established by state and federal government guidelines.
当前的程序术语（CPT-4）codes Medical professionals use this set of five-digit codes for billing.
d
可扣除the amount an individual must pay for health care expenses before insurance (or a self-insured company) covers the costs. Often, insurance plans are based on yearly deductible amounts.
家属被保险人的配偶和/或未婚子女（无论是自然，被收养还是步骤）。
诊断相关组（DRG）DRG是一种分类住院住宿的系统。医疗保险和医疗补助服务中心使用DRG来得出医疗程序的标准报销率，并为医疗保险接受者支付医院。一些州为所有付款人使用DRG，一些私人健康计划使用DRG进行签约。
e
effective Datethe date your insurance is to actually begin. You are not covered until the policies effective date.
exclusionsmedical services that are not covered by an individual's insurance policy.
解释利益一种n explanation of benefits is a statement mailed to an insured person that details which services it has paid for and which services the insurer did not cover, along with an explanation on why it wasn’t covered. Medicare recipients receive a Medicare Summary Notice (MSN).
G
集团保险e Coverage through an employer or other entity that covers all individuals in the group.
H
HCF一种1500 formMedicare要求使用HCFA 1500表格，并由一些私人保险公司和管理账单管理计划使用。
健康维护组织（HMO）Health Maintenance Organizations represent "pre-paid" insurance plans in which individuals or their employers pay a fixed monthly fee for services, instead of a separate charge for each visit or service. The monthly fees remain the same, regardless of types or levels of services provided. Services are provided by physicians who are employed by, or under contract with, the HMO. HMOs generally use primary care doctors to determine whether members receive care from specialists.
H一世p一种一种一种Federal law passed in 1996 that allows persons to qualify immediately for comparable health insurance coverage when they change their employment or relationships. It also creates the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care. Full name is "The Health Insurance Portability and Accountability Act of 1996."
一世
一世n-network提供者或医疗保健设施是健康计划网络的一部分，它与之协商了折扣。被保险人通常在使用网络内提供商时支付的费用较低，因为这些网络以较低的成本为签订合同的保险公司提供服务。
一世ndividual Health InsuranceHealth insurance coverage on an individual, not group, basis. The premium is usually higher for an individual health insurance plan than for a group policy, but you may not qualify for a group plan.
一世nternal Classification of Disease (ICD) codes一世Cdcodes are an international disease classification system used in diagnosis and treatment.
l
lifetime Maximum Benefit (or Maximum Lifetime Benefit)健康计划将在该个人的一生中向被保险人支付的最高金额。
limitations限制了保险证书所披露的特定涵盖费用所支付的福利金额。
loslosrefers to the length of stay. It is a term used by insurance companies, case managers and/or employers to describe the amount of time an individual stays in a hospital or in-patient facility.
m
managed Health Caremanaged health care refers to a system of health care delivery that tries to manage the costs and quality of health care and access to care. It often involves use of contracted provider networks, limitations on benefits for care given by noncontracted providers (unless authorized to do so) and use of care authorization systems. Managed care includes managed indemnity plans, preferred provider organizations, point-of-service plans, open-panel HMOs and closed-panel HMOs.
medicaidmedicaid is a program financed jointly by the federal government and the states that provides health care coverage and nursing home care for low-income people. Benefits vary widely from state to state.
medicareMedicare是一项联邦计划，确保年龄在65岁及以上的人和各个年龄段的残疾人。Medicare A部分涵盖了住院，熟练的护理设施护理和/或家庭健康机构的服务，这是一个强制性的好处。Medicare B部分涵盖了针对医师，外科医生或任何专业技术人员的费用的门诊服务，并且是自愿的福利。
MedigapMedigapis private insurance that supplements Medicare reimbursement for medical services. Medicare often reimburses care at lower rates than those charged by doctors. Medigap is meant to cover the gap between Medicare reimbursement and provider charges so that the Medicare recipient doesn’t have to pay the difference.
n
network一种group of doctors, hospitals and other health care providers contracted to provide services to insurance companies’ customers for less than their usual fees. Provider networks can cover a large geographic market or a wide range of health care services. Insured individuals typically pay less for using a network provider.
o
网络外this phrase usually refers to physicians, hospitals or other health care providers who are considered nonparticipants in an insurance plan (usually an HMO or PPO). Depending on an individual's health insurance plan, expenses incurred by services provided by out-of-network health professionals may not be covered, or covered only in part by an individual's insurance company.
out-Of-Pocket Maximum个人必须从保险公司或（自给自足的雇主）之前支付的预定数量有限的钱，将为个人的医疗保健费用支付100％的费用。
门诊一种n individual (patient) who receives health care services (such as surgery) on an outpatient basis, meaning they do not stay overnight in a hospital or inpatient facility. Many insurance companies have identified a list of tests and procedures (including surgery) that will not be covered (paid for) unless they are performed on an outpatient basis. The term outpatient is also used synonymously with ambulatory to describe health care facilities where procedures are performed.
p
pre- Certification预认证是从常规医院入院（住院或门诊病人）中获得授权的过程。未能获得预认证通常会导致减少索赔的报销或拒绝。
preadmission Testingmedical tests that are completed for an individual prior to being admitted to a hospital or inpatient health care facility.
首选提供商组织（PPO）preferred provider organizations contract with independent providers for services. The doctors in a PPO are paid on a fee-for-service schedule that is discounted below standard fees. The panel of providers is limited, and the PPO usually reviews health care utilization. PPO members sometimes can use a doctor outside the PPO network, but usually must pay a bigger portion of the fee.
初级保健提供商（PCP）一名医疗保健专业人员（通常是医生）负责监测个人的整体医疗保健需求，将个人转介给更专业的医生进行专业护理。
provider提供者是一个术语用于健康专家who provide health care services such as doctors, hospitals, nurse practitioners, chiropractors, physical therapists, and others offering specialized health care services.
r
合理和习惯的费用平均费用收取d by a particular type of health care practitioner within a geographic area. The term is often used by medical plans as the amount of money they will approve for a specific test or procedure. If the fees are higher than the approved amount, the individual receiving the service is responsible for paying the difference. Sometimes, however, if an individual questions his or her physician about the fee, the provider will reduce the charge to the amount that the insurance company has defined as reasonable and customary.
s
second Opinion一世t is a medical opinion provided by a second physician or medical expert. Individuals are encouraged to obtain second opinions whenever a physician recommends surgery or presents an individual with a serious medical diagnosis.
自保险计划一世n self-insured (self-funded) plans, the employer (rather than an insurance company or managed care plan) assumes the risk of medical costs. Self-funded plans are exempt from state laws and regulations such as insurance premium taxes and mandatory benefits. Self-funded plans often contract with insurance companies or third party administrators to administer the benefits.
skilled nursing facility (SNF)熟练的护理设施通常是康复或疗养院的机构。熟练的护理设施为长期或急性疾病提供了高水平的专业护理。
停止损失the dollar amount of claims filed for eligible expenses at which point you've paid 100 percent of your out-of-pocket and the insurance begins to pay at 100%. Stop-loss is reached when an insured individual has paid the deductible and reached the out-of-pocket maximum amount of co-insurance.
你
你sual, Customary and Reasonable (UCR) or Covered Expenses反映某个地区的服务费用。许多保险公司和托管护理计划根据UCR指控偿还提供商。
w
等待期一段时间以来，您没有为特定问题保险覆盖。