Universal coverage- A system of health care where everyone is covered, even if they can not afford it. In some cases, it may be a type of government sponsored health plan which would provide health care coverage to all of its citizens.
Pre-certification- A process that evaluates the appropriateness and medical necessity of hospitalization or surgery, and determines if medical expenses should be approved or denied for the service being rendered.
Deductible- The out of pocket expense for covered medical services that an insured person must pay before the insurance company or health plan pays any benefits. For example, a health plan may require the member to pay the first $500 of covered expenses during a calendar year before reimbursement begins.
Premium- The monthly payment made by the health insurance policyholder (insured person, member or subscriber) to an insurace company to iniate and/or keep existing insurance coverage.
Copayment- A cost sharing arrangement in which a plan member (covered person) pays a specified charge for a health care service, such as $10 for an office visit. The member is usually responsible for payment at the time the health care is rendered.
Credentialing- The process of reviewing a practitioner's credentials for the purpose of approving his/her eligibility for hospital, PHO, or medical staff membership.
Subrogation- In employee benefit plans, the right of the employer or insurance company to recover benefits paid to participants through legal suit, if the action causing the disability and subsequent medical expenses was the fault of another individual.
Gatekeeper- A primary care provider who serves as a patient's initial contact for medical care and specialty care referrals or hospital admission.
Case rate- A flat fee paid to a provider to cover all services for a patient's treatment based on diagnosis (episode of care), such as