Definition

Business professional who analyzes probabilities of risk and risk management including calculation of premiums, dividends and other applicable insurance industry standards.

Process used by payers to determine benefit or coverage eligibility, as well as the determination of the payment amount for a claim or the denial of a claim.

An arrangement in which an organization funds its own employee benefit plan but hires an outside firm to perform specific administrative services. For example, an organization may hire an insurance company to evaluate and process claims under its employee health plan while maintaining the responsibility to pay the claims itself.

Licensed salespersons that represent a health insurance company and is allowed to present their products to consumers.

The maximum dollar amount or total amount of coverage payable for a single loss, or multiple losses, during a policy period, or on a single project.

The maximum amount a health care plan will cover for services rendered at a provider. From the health plan’s perspective, this is the fair and reasonable price for a health care service.

Medical treatment that is not deemed effective by the medical community at large. Examples may include acupuncture and aromatherapy. Coverage of these types of services may not be provided by a majority of insurance companies.

Medical care performed on an outpatient basis. Services often include diagnosis, treatment, surgery and rehabilitation.

In 1979, ANSI chartered the Accredited Standards Committee (ASC) to create a standard for submission of electronic medical bills or Electronic Data Interchange (EDI). The Institute oversees the creation of norms and guidelines for nearly every sector of industry.