Allowable Benefits – The maximum amount decided arbitrarily by the insurance company, according to the individual policy, that insurance will pay for each procedure or service performed.

Insurance Claim – An itemization of covered medical expenses sent to an insurance company.

Referral – An authorization given by the insurance company to the Primary Care Physician for transfer of medical care to a specialist for treatment limited to a specific disorder.  Necessary for some plans, i.e. HMO’s.

Primary Care Physician – A family practice, internal medicine, pediatric, and, in some plans, OBGYN responsible for providing all routine primary health care for the patient and providing needed referrals to specialists.

Contract – An agreement between two or more parties to perform specific services or duties.

Benefits – An amount payable by an insurance company to the insured or the insured’s designated health care provider for covered medical expenses.

Exclusions – Disorders, diseases, or treatments listed as uncovered services (not reimbursable) in an insurance policy.

Reasonable and Customary – A phrase used by the insurance company to justify their set prices for reimbursement.  It has nothing to do with either reasonable or customary.

Co-pay – The amount the insurance plan requires a patient to pay the health care provider for each office visit at the time the service is performed.

Deductible – The part of the allowable cost of a covered medical procedure that insurance does not pay and that a patient is responsible for paying.

Elective – Deemed not medically necessary to save life or limb.  Cosmetic surgery is elective surgery.

Preauthorization/Precertification – Getting approval for a procedure from a patient’s insurance plan before the procedure is done.

Pre-existing Condition – an insurance term for a medical problem a patient had before he was covered by that insurance plan that may not be covered by the new plan for a period of time.