Glossary

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Accreditation

A term typically applied to hospitals and other health care facilities, as well as certain health benefits plans, indicating that the facility or plan has met operating, quality and other standards established by a third party review agency.

Adjudication

The process used by health plans to determine the amount of benefit payment for a covered health care service. The term usually refers to the processing of a health care claim. The process includes a review of whether the service is covered by the health plan and whether deductibles, co-insurance, co-payments or other benefit limits apply.

Advanced (Advance) Directives

Sometimes called a "living will." An Advance Directive is a legal document that tells your physician what kind of care you want (and what kind of care you don't want) if you become ill and can't make medical decisions or communicate your decisions (for example, if you are in a coma). Hospital staff will routinely ask you if you have an Advance Directive when you are admitted to the hospital. Laws about Advance Directives vary in each state. You should be aware of the laws in your state. If you have an Advance Directive, be sure both your family and your physician have copies and are aware of your wishes.

Allowable Expense(s)

Also a "covered expense." Refers to amount of a charge for medically necessary health care that is "covered," or eligible to be paid by a health benefits plan.

Ambulatory Care

See Outpatient Care

Annual Limits

A limit on the amount your plan will pay in a year while you're enrolled in a health plan. Limits are sometimes placed on prescription drugs or hospital stays. After an annual limit is reached, you must pay the rest of your health care costs for the year.

Appeals process

A process maintained by an employer or health plan that allows an individual to appeal an adverse benefit decision. If all or part of your claim is denied and you believe this decision is in error, you may use the appeals process to initiate an additional review of the claim. In some cases, your plan may not have had enough information to make a decision, and the appeals process gives you the opportunity to provide that information. To find out about your plan's appeals process, visit the health plan's website or call the toll-free number on your ID card.

Authorization

A health plan's process for approving payment for medical services covered by an individual's benefits plan. Depending on the plan, such authorization may be required before services are rendered (see Pre-authorization/Precertification).

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