Quick Healthcare Dictionary

Ancillary Services:

Professional services such as laboratory tests and radiology exams. Often ancillary locations are separate from physicians’ offices.

Co-payment:

A payment made by an individual who has health insurance, usually at the time a service is received. Co-payments are determined by the individual’s health plan, and are common with HMO (Health Maintenance Organization) and PPO (Preferred Provider Organization) plans. They also vary depending on the service: low co-payments are required for routine doctor visits, while higher co-payments are required for emergency room visits. (Also called co-insurance.)

Deductible:

A set dollar amount which must be satisfied within a specific time frame before the health plan begins making payments on claims. The deductible requirement applies each year of the policy.

Explanation of Benefits:

A written summary of the payments made by your health insurer or employer to the medical provider you saw. This usually comes in the mail to your home 3-4 weeks after you see a doctor.

HMO (Health Maintenance Organization):

An organization that arranges healthcare for its voluntarily enrolled individuals and families, who pay monthly premiums. The HMO arranges for this care either directly in its own group practice and/or through doctors and other health care professionals under contract. Your choices of doctors and hospitals are limited to those that have these agreements with the HMO. Co-pays apply.

In-Network Claim:

A medical bill produced after you see a doctor who is enrolled in an HMO, PPO, or other managed care entity. Your health plan pays the high majority of these claims. See your employer for a list of doctors in your network.

Out-of-Network Claim:

A medical bill produced after you see a doctor who is not enrolled in an HMO, PPO, or managed care entity. If you visit a doctor who is out-of-network, you must pay the difference between what the provider charges and what the health plan pays.

Out-of-Pocket Expense:

The amount the patient must pay themselves and not paid for by the insurance plan.

Participating Provider:

A physician or other medical provider has agreed to accept a set fee for services provided to members of a specific health plan. They are deemed to be "in-network".

Provider:

A person, hospital, or other treatment facility that helps in identifying, preventing, treating sickness or disability.

PPO (Preferred Provider Organization):

An organization that negotiates arrangements with doctors, hospitals and other healthcare providers who accept lower fees from the insurer for their services in exchange for steerage.

Reimbursement:

Payment made to physicians by a patient's insurer. Payment amounts are based on fee schedules that are published by each insurer.