Accounts Receivable Coverage
This coverage lets you extend insurance protection to your accounts receivable records. If your accounts receivable records are ever damaged or destroyed by a covered loss, your insurance will pay to replace or restore them. Most policies offer between $10,000 and $25,000 for this coverage.

Advertising Injury
If you are sued because of something that happened during the course of advertising your company's goods, products, or services, this coverage will provide liability protection. Advertising injuries can result from:

• Publishing or broadcasting inaccurate information that slanders
  or libels a person or organization
• Publishing material that violates a person's right of privacy
• Copying another company's advertising ideas or style of
  doing business
• Infringing on another company's copyright, title, or slogan

Animal Bailee Coverage
If you are a veterinarian, you may want animal bailee coverage added to your insurance program. This coverage is specifically designed to protect you if you are sued because animals in your care, custody, or control are accidentally killed or injured.

Automobile Liability
This is part of the basic auto policy. It protects you if someone claims that you or anyone driving your covered auto is legally liable for either bodily injury or property damage. This includes liability that you incur while driving a rented or leased vehicle. For more information, please see Automobile.

Accreditation
An evaluative process in which a healthcare organization undergoes an examination of its operating procedures to determine whether the procedures meet designated criteria as defined by the accrediting body, and to ensure that the organization meets a specified level of quality.

Active Contract
A member that currently has coverage with Empire.

Actual Charge
The amount a physician or other practitioner actually bills a patient for a medical service or procedure.

Acupuncture
A traditional Chinese medical practice of insertion of fine needles into specific exterior body locations to relieve pain, to induce surgical anesthesia, and for therapeutic purposes.

Acute Illness
A physical condition or illness that begins abruptly and requires medical care or restricted activity for a short period of time (usually 3 months or less).

Adjudication
The process by which a claim is paid or denied based on eligibility and contract determination.

Admission
Formal acceptance as an inpatient by an institution, hospital or healthcare facility.

Admitting Physician
The physician responsible for admission of a patient to a hospital or other inpatient health facility

Advance Directive
Any spoken or written decision with your instructions and preferences for medical treatment. If you sign an advance directive, your family and your doctor will know who to talk to about your care or what kinds of treatment you want or don't want if you are too sick or incompetent to decide. If you become unable to make decisions about your health care treatment, your family may not be able to make decisions for you unless you sign a health care proxy directive. Please visit the NY State Dept. of Health site for more information.

Aggregate Family Deductible
A deductible which is met when two or more family members' charges are added together to meet a family deductible.

Allergy Treatment
The treatment of the allergic patient may include identifying the offending agent by means of various testing methods. Once the agent is identified, treatment is provided by avoidance, medication, or immunotherapy.

Allowable Charge
The maximum fee that a health plan will reimburse a provider for a given service.

Allowance
The amount an individual provider/member is entitled to receive for a certain service.

Allowed Amount
The maximum reimbursement the member's health policy allows for a specific service in or out of network. This amount may be:

• a fee negotiated with participating providers
• a customary charge based on the amount -charged by most
  providers in the member's area
• an allowance established by law
• an amount set on a Fee Schedule of Allowance

Ambulatory Care
All types of health services that are provided on an outpatient basis.

Ambulatory Care Facility
A medical care center that provides a wide range of healthcare services, including preventive care, acute care, surgery and outpatient care in a centralized facility.

Ambulatory Surgery
Surgical procedures performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Also called Outpatient Surgery.

Ancillary Services
Auxiliary or supplemental services (i.e. diagnostic services, physical therapy, medications) used to support diagnosis and treatment of a patient's condition.

Annual out-of-pocket Coinsurance Maximum
The most you will have to pay in out-of-pocket costs for coinsurance on covered services during a calendar year. Charges in excess of the allowed amount (see definition) are not applied toward this maximum.

Appeal(s)
A process used by a provider or member to request the health plan reconsider a previous authorization or claim decision.

Assignment
An agreement in which a patient assigns to another party, usually a physician or hospital, the right to receive payment from a public or private insurance program for the service the patient has received.

Attending Physician
Physician primarily responsible for the care of a patient during hospitalization.

Authorization
See 'Pre-Authorization'

Authorized Services
See 'Precertified Services'.

Accelerated Benefits
Benefits available prior to death, to help pay the costs of long-term care or terminal illness. Life insurance riders which allow the policy's death benefits to offset expenses incurred in a convalescent or nursing home facility

Access
Availability of medical care. Determined by availability of transportation, location, type of medical services in the area, etc.

Accident Insurance
Insurance against loss by accidental bodily injury to the insured.

Accidental Death and Dismemberment (AD & D)
Policy or provision in a Disability Income policy that pays a specified amount or a multiple of the weekly disability benefit should the insured die, lose his sight, or lose two limbs as the result of an accident. Lesser amount is payable for the loss of one eye, arm, leg, hand, or foot.

Accidental Death Benefit
Extra benefit that, in general, equals the face of the contract or principal sum, payable in addition to other benefits in the event of death as the result of an accident. A provision added to a life insurance policy for payment of an additional benefit if death is caused by an accident. Sometimes called "double indemnity."

Accidental Death Insurance
Form of insurance providing payment if the death of the insured results from an accident. Often combined with Dismemberment Insurance in a form called Accidental Death and Dismemberment.

Activities of Daily Living
Activities performed by individuals without assistance in the course of day to day living that include mobility, dressing, personal hygiene and eating.

Activities of Daily Living Standards
Standards assessing the ability of an individual to live independently, measuring the ability to perform unaided such activities as eating, bathing, toiletry, dressing, and walking. Standards are often discussed as a measurement or definition of eligibility for long term care.

Actual Charge
Actual amount charged by a physician for medical services.

Acute Care
Medically necessary, skilled care provided by nursing and medical personnel to restore a person to good health.

Additional Drug Benefit List
Prescription drugs listed as commonly prescribed for patients' long-term use. Subject to review and revision by the health plan involved. Also referred to as drug maintenance list.

Additional Monthly Benefit
Riders added to disability income policies to providing additional benefits for the first year of a claim while the insured is waiting for commencement of Social Security benefits.

Adult Day Care
Group program for functionally impaired adults. Meets health, social and functional needs in a setting other than adult's home.

Aftercare
Patient services, customized to the individual, required after hospitalization or rehabilitation.

Age Change
For insurance purposes, date that a person's age changes. In majority of Life Insurance contracts, defined as the date midway between the insured's natural birth dates. For Health Insurance purposes, the age of the previous birth date is frequently used for rate determinations. Based upon the rating structure of the particular insurer, on the date of age change, a person's age may change to that of the last birth date, the nearer birth date, or the next birth date.

Annuity
A contract between a private individual and a life insurance company. The individual pays a sum of money that is invested and in return the insurance company makes periodic payments to the individual as specified in the contract. Annuities are primarily used as a vehicle for retirement income.

Base Capitation
Total amount covering cost of health care per person, minus mental health or substance abuse services, pharmacy, and administrative charges.

Basic Hospital Expense Insurance
Benefits provided by hospital coverage for room and board and miscellaneous hospital expenses for specified number of days during hospital confinement.

Bed Days/1,000
Number of inpatient hospital days per 1,000 members of the plan.

Beneficiary
The person or entity, such as a trust fund, named in a life insurance policy as the recipient of policy proceeds in the event of the policyholder's death.

Benefit Levels
Maximum amount a person is entitled to receive for particular services as described in the contract with insurer or health plan.

Benefit Package
Description of services offered by insurer or health plan to those covered under the terms of health insurance contract.

Benefit Period
Period during which Medicare beneficiary is eligible for Part A benefits. Benefit period is 90 days, beginning the day of patient's admission to hospital and ending when individual has not been hospitalized for a period of 60 consecutive days.

Billed Claims
Amounts submitted by health care provider for services provided to a covered individual.

Birthday Rule
A method determining which parent's medical coverage is primary for dependent children: parent whose birthday falls earliest in the year is considered to have primary plan.

Blanket Insurance
Health Insurance contract covering all of a class of persons not individually identified in the contract.

Blanket Medical Expense
Policy or provision in Health Insurance contract that pays all medical costs, including hospitalization, drugs, and treatments, without limitation on any item except for possibly a maximum aggregate benefit under the policy. Frequently written with an initial deductible amount.

Board Certified
Physician or other professional who has passed an examination certifying him as a specialist in a particular medical area.

Board Eligible
Professional person or physician eligible to take a specialty examination.

Business Overhead Expense
Disability income policy indemnifying the business for specified overhead expenses incurred should the business owner become totally disabled.

Balance Billing
Billing a member or other responsible party for the difference between the insurer's payment and the actual charge.

BCBSA
See 'Blue Cross and Blue Shield Association'.

Behavioral Healthcare
The provision of mental health and substance abuse services.

Benefit(s)
Services available to a member as defined in the contract. Benefit design includes the types of benefits offered, limits (e.g. number of visits, percentage paid or dollar maximums applied), subscriber responsibility (cost sharing components), and subscriber incentives to use network providers.

Benefit Period
The way that Medicare measures the use of hospital and skilled nursing facility services. A benefit period begins the day a member enters a hospital or skilled nursing facility and ends when hospital or skilled nursing care has not been received for 60 consecutive days. A new benefit period begins when the member enters the hospital after the previous benefit period has ended. A new inpatient hospital deductible is payable for each benefit period.

Benefits Exhausted
When the maximum number of visits for a specific service is reached, further benefits will not be considered.

Billed Fee
The amount charged by a provider for a specific service.

Billing Address
The address to which a billing statement will be sent.

Blue Cross and Blue Shield Association (BCBSA)
A corporation formed by the BlueCross BlueShield plans to establish national standards and act as a national coordinating agency. The association headquarters are in Chicago, IL.

BlueCard Access
A toll-free 1-800 number, 1-800-810-BLUE, Customer Service Representatives and members can use to locate providers in another BlueCross BlueShield Plan's area. This number is useful when Customer Service Representatives need to refer the patient to a physician or healthcare facility in another geographic location.

BlueCard Worldwide Program
A program that allows BlueCross BlueShield members traveling or living abroad to receive inpatient and outpatient institutional and professional services from participating health care providers worldwide. The program also allows members of foreign BlueCross BlueShield Plans to access U.S. BCBS provider networks.

BlueCard Managed Care/POS Program
A health benefit program that covers employees of national companies. The highest level of benefits is received when members obtain services from their primary care provider/group and/or comply with referral and/or authorization requirements for care. Substantial benefits are still provided when members obtain care from any eligible provider without referral or authorization, according to the contract terms.

BlueCard PPO Program
A national program that offers members traveling or living outside of their BlueCross BlueShield Plan's area the PPO level of benefits when they obtain services from a physician or hospital designated as a BlueCard PPO provider.

Board Certification
A process by which a physician who has been tested for proficiency in a medical specialty or subspecialty, by a medical specialty board, has passed those tests and therefore been certified as proficient in that medical specialty.

Board Eligible
Denoting a physician who has completed the educational requirements necessary for eligibility to take the specialty board examinations.

Brand Name Drug
A prescription drug that has been patented and is only available through one manufacturer.

Binder
A document that provides proof of insurance in the interim between purchasing the insurance and receiving your actual policy.

Bodily Injury
This coverage pays your legal liability for bodily injury, including: Cost of care Loss of services Restitution for any death resulting from the injury Some carriers include coverage for mental anguish. If a customer is physically injured by you and claims that he or she suffered mental anguish as a result of the injury, this coverage applies to both physical injury and mental anguish.

Boiler & Machiner
Don't let the name fool you
boiler and machinery coverage provides much more. It covers refrigeration equipment, air conditioning equipment, transformers, electric motors, generators, turbines, engines, compressors, pumps, blowers, types of piping, gearing, shafting, and various other mechanical and electrical equipment. Most normal policies will not provide coverage for these types of machinery, so we recommend that every company purchase boiler and machinery coverage.
Borrowed Equipment (Property Damage)
Historically, commercial General Liability policies have not covered you if you are held legally responsible for physically damaging either property that is loaned to you or personal property that is in your care, custody or control (such as your customers' personal belongings). However, some policies have begun providing small limits for this coverage.

Brands & Label Coverage
In case of a covered loss, this provision pays the cost of removing the brands and labels from damaged stock so that the damaged stock can be salvaged.

Broadened Coverage for Extra Expense
This coverage pays any extra expenses involved in returning an insured automobile that was stolen and recovered.

Builders Risk
While a normal Property policy covers a building and specific contents, it does not provide coverage to a building that is under construction. Builders Risk insurance provides just that. It covers loss or damage to a building under construction and may also include coverage for items located on site or in route to the site.

Building Ordinance
Building Ordinance (sometimes called Ordinance or Law) coverage provides for additional construction or demolition costs incurred, as the result of a covered loss, where the present building codes require more expensive designs or materials than were required at the time your building was originally constructed. Essentially, if your building incurs damage, you may be required by law to repair your building to meet current building laws or specifications. This may mean that if part of your building is damaged, you may be required to demolish and remove the entire building and replace it with one conforming to new building codes. If complete demolition and removal is not necessary, you may be required to bring the existing building up to code.

Business Interruption
Business interruption provides coverage when your business suffers a loss and is unable to operate at normal capacity. For example, if your business is destroyed by a fire, Business Interruption will reimburse your continuing expenses, such as rent, payroll, and electricity, until your business gets back on track or until you reach your limit of insurance

Business Owners Policy (BOP)
The Business Owners Policy (BOP), is a group of different types of coverages combined into a neat package to meet most of the insurance needs of the typical small-to-medium sized business. A BOP policy usually contains Property (Buildings, Business Personal Property and Business Income and Extra Expense) General Liability, and Non-owned & Hired Auto Liability coverages. For more information, please see Business Owners Policy.

Certificate of Insurance
A Certificate of Insurance verifies that a policy has been written and states the coverage in general. It is often used as proof of insurance in loan transactions and for other legal requirements.

Claim Expense
This provision pays for expenses you incur to assist an insurance company in investigating a claim or determining the amount of a covered loss.

Collision
Collision coverage protects you in case your vehicle is physically damaged in an accident involving another vehicle or a stationary object, such as a building, telephone pole, or guardrail.

Commercial General Liability
A Commercial General Liability (CGL) policy provides your business with protection from lawsuits brought by third parties alleging bodily injury, property damage, personal injury, and advertising injury. In addition, the policy pays any sums you are legally obligated to pay in damages up to the applicable policy limit. For more information, please see Commercial General Liability.

Carrier
An insurance company that either administers insurance or self-insures.

Carryover (4th Quarter) Deductible
An option sometimes contained in a health insurance contract where deductible amounts incurred under a member's contract in the last three months of the year are applied towards the deductible of the next calendar/benefit year.

Carve Out Contract
See: Medicare Carve Out Contract

Case Management
A program that assists the patient in determining the most-appropriate and cost effective treatment plan including coordinating and monitoring the care with the ultimate goal of achieving the optimum healthcare outcome.

Certificate of Coverage (Certificate)
A plan booklet that describes the benefits, features, and services of a health plan.

Certification
process in which an individual, an institution, or an educational program is evaluated and recognized as meeting certain predetermined standards. Certification usually applies toward individuals and accreditation usually applies toward institutions.

Charges not Covered
Provider changes that exceed the insurer's payment for services, or services not covered by your health policy

Chemotherapy
Treatment of malignant disease by chemical or biological antinoeplastic agents.

Chiropractic Care
An alternative medicine therapy administered by a licensed Chiropractor. The chiropractor's specialty is the relief, correction and prevention of musculo-skeletal problems of the spine, peripheral joints and related areas through manipulation.

Chronic Care
A pattern of medical care that focuses on long-term care with chronic diseases or conditions.

Claim
An itemized statement of healthcare services and their costs provided by hospital, physician's office or other healthcare facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

Claim Form
An application for payment of benefits under a healthcare plan.

Clinical Decisions
A clinical decision is a decision about your medical treatment.

Clinical Issues
A clinical issue is information relating to your health.

Clinical Professionals
Doctors, nurses and other healthcare professionals are clinical professionals.

Clinical Reviews
A clinical review is when a clinical professional reviews information about your health.

COB
See 'Coordination Of Benefits'.

COBRA
See 'Consolidated Omnibus Budget Reconciliation Act'.

Coinsurance
Cost-sharing requirement that the insured pay a designated percentage of the allowed amount for covered services.

Coinsurance Maximum
The most you will have to pay in out-of-pocket costs for coinsurance on covered services during a calendar year.

Complaint
A verbal or written inquiry from a member or provider expressing dissatisfaction with any aspect of their care, coverage or specifically with Empire.

Concurrent Care
Medical care rendered within the aftercare period of surgery, by other than the surgeon, and the condition is different from the one treated surgically.

Consolidated Omnibus Budget Reconciliation Act (COBRA)
A federal act which requires each group's health plan to allow employees and certain dependents to continue their group coverage for a stated period of time following a qualifying event that causes the loss of group health coverage. Qualifying events include reduced work hours, death, or divorce of a covered employee and termination of employment.

Consultation
Services rendered by a physician whose opinion or advice is requested by another physician for further evaluation or management of the patient.

Continuation of Coverage
Procedure by which individuals transferring from one insurance plan to another are allowed uninterrupted coverage from the date of original enrollment.

Contraception
The process by which pregnancy is prevented by either barring conception of an embryo or the implantation of it within the uterine wall.

Contract
A legal agreement between an individual subscriber or an employer group and a health plan that describes the benefits and limitations of the coverage.

Contract Holder
The individual in whose name a contract is issued or the employee covered under an employer's group health contract. The subscriber can enroll dependents under family coverage.

Conversion
A change of a customer's contractual status involving the method of payment of subscription charges and possible types of coverage. For example, a member may transfer from a group policy to direct payment coverage upon termination of employment.

Coordination of Benefits (COB)
The provision which applies when an enrollee is covered by two health plans at the same time. The provision is designed so that the payments of both plans do not exceed 100% of the covered charges. The provision also designates the order in which the multiple health plans are to pay benefits. Under a COB provision, one plan is determined to be primary and its benefits are applied to the claim first. The unpaid balance is usually paid by the secondary plan to the limit of its responsibility. Benefits are thus "coordinated" between the two health plans.

Co-payment (or co-pay)
The fixed dollar amount that your policy requires you to pay as your share of the cost of certain services each time you receive care.

Cost Sharing
The provision of a health insurance policy that requires insured individuals to pay some portion of the covered medical expenses. Several forms of cost sharing are deductible, copayment and coinsurance.

Covered Services
The services for which Empire provides benefits under the terms of your contract.

Custodial Care
Maintenance care of a patient which is designed to assist the patient in daily living and not primarily provided for the treatment of an illness, disease or condition. Custodial care includes but is not limited to help in walking, bathing and feeding.

Customary and Reasonable (C&R)
The amount customarily charged for the service by other physicians in the area (often defined as a specific percentile of all charges in the community), and the reasonable cost of services for a given patient after medical review of the case. Also called "Usual, Customary and Reasonable" (UCR).

Customary Charges
The fees most providers charge for a certain procedure. These charges are determined based on charge data collected from providers in a geographical area at a certain time period.

Compensation for Family Members
If an injured worker's family members can prove that you are legally liable for a work-related injury or illness, they may be able to collect damages from you. In such cases, the Employer's Liability coverage provided by your policy may pay for: Compensation for family members for their "loss of consortium" or access to the injured worker Damages to spouses or relatives that result from the injury to the spouse or relative

Comprehensive
Comprehensive coverage pays for physical damage to your insured autos caused by a variety of risks, including fire, lightning, theft, vandalism, hail, and flood.

Computers and Media
If you have a covered loss, and you incur damage to your computer(s) or computer systems, you are likely to incur more than just the cost of new equipment. You are likely to incur business losses when new computers are being ordered or repairs are being made. You are likely to also incur the expense of renting temporary equipment and the loss related to re-entering lost information. Although the BOP provides a limited amount of Computer and Media coverage, generally the level of coverage is not enough to protect your business in the event of a loss.

Consequential Loss to Stock
Consequential Loss to Stock coverage reimburses you for financial loss in situations where damage to one part of your inventory also reduces the value of related but undamaged components.

Contractor's Equipment
There are four main types of equipment that are covered under this policy: 1) equipment that is owned by you and used in your business; 2) equipment that is leased or rented; 3) equipment that is in transit to or is temporarily located on any premises owned, leased, or operated by you; 4) equipment that is located temporarily at a private residence but that is owned by the insured.

Contractual Liability
This coverage extends to any liability you may assume by entering into a variety of contracts, including: a building lease any easement of license agreement an agreement to indemnify a town or city if required by ordinance an elevator maintenance agreement This coverage does NOT cover your obligations assumed in a contract. It only responds to tort liabilities that you have assumed in a contract. For example, if you contractually agree to deliver goods on December 15, 2000, and fail to do so, you have violated a contractual obligation. There would be no coverage for that.

Counterfeit Money Orders and Paper Currency
This coverage reimburses you for financial loss if a customer pays you with counterfeit money orders or paper currency.

Covered Parties
In general, Workers' Compensation insurance is designed to provide benefits for your employees. However, individuals that are defined as employees are determined by state law. And in Workers' Compensation cases, courts typically have been very liberal in their definition of employees, so as to provide injured workers with broad protection under the state's Workers' Compensation laws. The Employer's Liability insurance included in your Workers' Compensation policy can also provide damages to injured workers separate from their Workers' Compensation benefits. Family members and other third party claimants may also receive benefits under this coverage if they prove the employer's legal liability.

Crime
Crime coverage is available in many forms. Individual policies state the specifics. In general, crime coverage covers money and securities and any tangible property that has intrinsic value but is not listed on the property coverage form. Crime forms may cover burglary, extortion, mysterious disappearance, robbery, safe burglary, or theft (larceny). Because crime coverage varies significantly between policies, we recommend that you understand what is and is not covered under your current policy.

Calendar Year
January 1 through December 31 of the same year. Under major medical plans, many deductible amount provisions are on based a calendar year. Benefits under basic hospital surgical and medical plans are based on an amount per calendar year.

Capitation (CAP)
A rate paid to health care provider, usually monthly. The provider agrees to deliver health services as agreed upon to covered person.

Carrier
Commercial insurer contracted by the Department of Health and Human Services to process payment of Part B claims.

Carrier Replacement
A situation where one carrier replaces another carrier or carriers.

Carry Over Provision
For major medical policies, an insured who has submitted no claims during the year can apply any medical expenses incurred in the last three months of the year toward the next calendar year's deductible.

Case Management
Assessment of a person's long term care needs and followed by appropriate recommendations for care, monitoring and follow-up as applies to extent and quality of services to be provided.

Case Manager
Person, usually experienced professional, who coordinates services necessary for case management approach.

Catastrophe Policy
An older name for Major Medical.

Catastrophic Disability
The total, permanent and irrevocable loss of speech, hearing in both ears, the sight of both eyes or the use of both legs, both arms, or one leg and one arm, due solely to a sickness or injury.

Certificate of Authority (COA)
State issued licensing the operation of an HMO (Health Maintenance Organization).

Certificate of Need (CON)
Government issued certification that the proposed facility meets the needs of those for whom it is intended. The need may involve constructing a new health facility, offering new or different health services, or acquiring new medical equipment.

COB
Coordination of Benefits. See Nonduplication of Benefits.

COBRA
See Consolidated Omnibus Budget Reconciliation Act of 1986.

Cognitive Impairment
Deficiency in ability to think, perceive, reason or remember. Results in loss of ability to attend to one's daily living needs.

Coinsurance Clause
Provision stating that insured and insurer will share all losses covered by the policy in a previously agreed upon proportion, i.e., 80-20 means the insurer would pay 80% and the insured would pay 20% of all losses. See also Percentage Participation.

Competitive Medical Plan (CMP)
Refers to permission given by the federal government allowing an organization to write a Medicare risk contract.

Composite Rate
One rate covering all members of the group regardless of their family status.

Comprehensive Major Medical
Insurance plan that has a low deductible, high maximum benefits, and a coinsurance feature. A combination of basic coverage and major medical coverage that has replaced separate hospital, surgical and medical policies with each having its own deductible requirements. Also see Major Medical Insurance.

Conditionally Renewable
Contract providing the insured may renew it to a stated date or an advanced age, that is subject to the right of the insurer to decline renewal only under conditions as previously stated in the contract.

Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986
Legislation providing a continuation of group health care benefits under the group plan for a period of time when benefits would otherwise terminate. Continuation rights apply to enrolled persons and their dependents. Coverage may be continued up to 18 months if the insured person terminates employment or is no longer eligible. Coverage may continue up to 36 months in other cases, such as loss of dependent eligibility because of death of the enrolled person, divorce, or attainment of the limiting age.

Contract Year
The period running from effective date to expiration date of contract.

Coordination of Benefits (COB)
Group policy provision that determines the primary carrier in situations when insured is covered by multiple policies. Prevents insured from receiving claims overpayments.

Co-pay
Arrangement where covered person pays a specified amount for specified services and health care provider pays remainder. Covered person usually pays his or her share when service is rendered. Unlike coinsurance which is a percentage, co-payment is a dollar amount.

CO-pay Provision
Often used with major medical policies. CO-pay provision states percentage of a claim the company will pay and percentage the insured will pay. Example, an 80% CO-pay provision the insurer pays 80% of claims and the insured pays 20%.

Cost of Living Benefit- Optional disability benefit where monthly benefit is increased annually once insured is on claim for 12 months.

Cost Sharing
Covered persons pay a portion of the health costs such as deductibles, coinsurance, or CO-payment amounts.

Covered Expenses
Health care expenses incurred by covered person that qualify for reimbursement under a policy contract.

Covered Person
Person who pays premiums to the contract for benefits provided and also meets eligibility requirements.

Custodial Care
Care primarily for meeting personal needs such as assistance in bathing, dressing, eating or taking medicine. Can be provided by someone without professional medical.

Date of Service
The date health service was provided.

Death Benefit
The amount paid to the beneficiary or beneficiaries of a life insurance policy if an insured dies.

Dependent Coverage
Insurance coverage on the head of a family which is extended to his or her dependents, including only the lawful spouse and unmarried children who are not yet employed on a full-time basis. "Children" may be step, foster, and adopted, as well as natural. Certain age restrictions on children usually apply. (LI,H)

Designated Mental Health Provider
Organization hired by health plan to provide mental health and substance abuse services.

Diagnosis
Disease identification.

Diagnosis Related Groups (DRGs)
Classification of inpatient hospital services. Used as method of determining financing to reimburse providers for services performed.

Disability (disabled)
A condition due to sickness or injury that curtails a person's ability to carry on normal pursuits. A disability may be partial or total, and temporary or permanent as verified by a doctor.

Disability Benefits Law
State law requiring employer to provide disability benefits to covered employees for non-occupational injuries. This is in contrast to Workers Compensation, which pays for occupational injuries. Laws are currently in effect in New York, New Jersey, Rhode Island, California, and Hawaii.

Disability Income Insurance
Form of health insurance providing periodic payments to replace income, actual or presumed loss, when sickness of injury results in the insured being unable to work. Provides periodic pay-outs when an insured is unable to work due to illness or injury as verified by a doctor.

Discharge Planning
Determination of the extent of patient's medical needs after discharge from a hospital or other inpatient treatment.

Dismemberment
Loss of, or loss of use of, specified members of the body resulting from accidental bodily injury.

Dismemberment Benefit
Benefits payable for various types of dismemberment. See also Accidental Death and Dismemberment and Multiple Indemnity.

Dividend
In life insurance, an amount of money returned to the holder of a policy. The money is a partial refund of the premium paid. Dividends are received when interest and expenses were more favorable than expected at the time the premiums were set.

Dread (or Specified) Disease Policy
Coverage, usually with a high maximum limit, for all of medical expenses as a result of diseases specified in the contract. Diseases covered are multiple sclerosis, poliomyelitis, spinal meningitis, diphtheria, and tetanus. Cancer is may be covered or added with some companies by a rider.

Dual Choice
Federal requirement for employers having 25 or more employees and within the service area of a federally qualified HMO, paying at least minimum wage and offering a health plan to their employees, must offer HMO coverage as well as an indemnity plan.

Duplicate Coverage Inquiry (DCI)
Request to determine whether or not other coverage exists. For use in applying the coordination of benefits provisions when two or more insurance companies are involved.

Duplication of Benefits
Identical or overlapping coverage exists between two or more insurance companies or service organizations.

Death Benefits
Death benefits are set by the state in terms of a maximum number of weeks' payment of wages. The benefit includes a flat amount for burial expenses as well as partial replacement of the worker's weekly wage.

Directors and Officers Liability Insurance
Insurance that protects and defends the personal assets of directors and officers from liability claims arising out of alleged errors in judgment, breaches of duty, and wrongful acts related to their organizational activities. These lawsuits may come from shareholders, employees, and potential business partners. For more information, please see Directors & Officers.

Disability Income Benefits
Includes compensation for lost wages.

Date of Service
The date on which a service was rendered.

Day Treatment Center
An outpatient psychiatric facility which is licensed to provide outpatient care and treatment of mental or nervous disorders or substance abuse under the supervision of physicians.

Deductible
Dollar amount that an insured person or family must pay each year before an insurer will assume any liability for the remaining cost of covered services.

Denial of Benefits
A rejection of an entire claim or part of a claim.

Dental Care
The treatment of the oral cavity.

Dependent
Person (spouse or child) other than the subscriber who is covered in the subscriber's benefit certificate. Also called a "Member" or "Beneficiary".

Diagnostic Service
A test or procedure rendered because of specific symptoms which is directed toward the determination of the definite condition or disease.

Diagnostic Tests
Tests and procedures ordered by a physician to determine if the patient has a certain condition or disease based upon specific signs or symptoms demonstrated by the patient. Such diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory, or pathology services.

Direct Payment
Individual subscribers who are billed and pay premiums directly to the insurer.

Discharge Date
Date the patient left the hospital.

Disease Management
A coordinated system of preventive, diagnostic and therapeutic measures intended to provide cost-effective, quality healthcare for a patient population who have or are at risk for a specific chronic illness or medical condition.

Domestic Partner
Such partners must be 18 years of age or older, unmarried and not related by marriage or blood in a way that would bar marriage or living together in a lifetime relationship that is financially interdependent. The partners must be each other's sole domestic partner and must have been involved in the domestic partnership for a period no less than six months.

Drug Formulary
A list of preferred pharmaceutical products that health plans, working with pharmacists and physicians, have developed to encourage greater efficiency in the dispensing of prescription drugs without sacrificing quality. Our Drug Formulary is available for download. Requires Adobe Acrobat reader.

Durable Medical Equipment
Mechanical devices, equipment and supplies which enable a person to maintain functional ability. Also called Medical Equipment.

Earthquake
Coverage provides for loss or property due to earthquakes or other earth movement.

Employee Benefits Liability
Employee Benefits Liability provides coverage to an employer for an error or omission in the administration of an employee benefit program, such as failure to advise employees of benefit programs, or from other negligent acts. Coverage also includes the administration of these plans.

Employee Dishonesty
Protects the employer from employee theft of money, securities, or property. Although the BOP provides a limited amount of Employee Dishonesty coverage, generally the level of coverage is not enough to protect your business in the event of a loss.

Employee/ERISA Dishonesty Coverage
If any of your covered employees commits a dishonest or fraudulent act which results in financial loss to your business, insurance coverage will reimburse you for the loss. This coverage can be amended to help you comply with ERISA. Most policies exclude coverage for employees who steal from you if they are known or convicted thieves.

Employee Tools
Coverage includes tools owned or leased by you, while the tools are temporarily located at any job site, or in transit to or between any job site. This coverage is similiar to Contractors' Equipment Coverage, but it is intended to cover tools as opposed to larger, higher-valued equipment.

Employer's Liability Coverage
This additional coverage provides employers with liability protection in case they are ever sued for damages arising from employment-related accidents or diseases. However, to collect benefits provided by Employer's Liability Coverage, both the employee as well as anyone else not covered by Workers' Compensation laws (such as spouses and dependents), would have to prove that the employer was actually legally responsible for the employee's injury or disease.

Employment Practices Liability (EPLI)
Protects the employer, directors & officers, and employees from claims arising from discrimination, wrongful termination or discipline, harrassment, failure to employ or promote, and other workplace torts. Although some companies may provide a nominal amount of coverage in this area, it is generally not a standard coverage included in a BOP. For more information please see Employment Practices Liability.

Equipment Breakdown Coverage
This coverage pays to repair or replace your equipment in case of breakdowns caused by losses that are typically excluded from most business insurance policie— like power surges, mechanical malfunctions, and boiler explosions. Among the many different types of equipment protected by this feature are computers, scanning equipment, phone systems, air conditioners, refrigeration systems.

Equipment Maintenance Insurance
This coverage takes the responsibilty of the maintenance service contracts off of you and passes it to a carrier.

Effective Date
The date on which the coverage of an insurance policy goes into effect at 12:01 a.m.

Elective Surgery
Surgery for a condition that is not considered an emergency.

Eligibility
A determination of whether or not a person meets the requirements to participate in the plan.

Eligibility Period
The period of time a group stipulates must elapse before a group member becomes eligible for benefits.

Emergency
An emergency is a medical or behavioral condition of which the onset is sudden. It manifests itself by symptoms of such severity that a prudent lay person with an average knowledge of medicine and health could reasonably expect that the absence of immediate medical attention would result in: placing the health of the afflicted person in serious jeopardy; placing the health of an individual with a behavioral health condition or others in serious jeopardy; causing serious impairment of the individual's bodily functions; causing serious dysfunction of any bodily organ or part; causing serious disfigurement of the afflicted individual.

Emergency Care
Care for patients with severe or life-threatening conditions that require immediate intervention.

Employee Retirement Income Security Act (ERISA)
This law, enacted in 1974, applies to employee benefit plans, including health benefits. The law is designed to protect the interest of employees and requires full disclosure to the employees of their rights under the plan.

Enrollee
An individual who is enrolled and eligible for coverage under a health plan contract. Also called "Member".

EOB
See 'Explanation Of Benefits'.

EOMB
See 'Explanation Of Medicare Benefits'.

EPO
See 'Exclusive Provider Organization'.

ERISA
See 'Employee Retirement Income Security Act'.

Exclusion
Specific conditions or circumstances that are not covered under the benefit agreement. It is very important to consult the benefit contract to understand what services are not covered benefits.

Exclusive Provider Organization (EPO)
A healthcare benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but which does not cover out-of-network care.

Experimental Procedures
Procedures that are mainly limited to laboratory research.

Expiration Date
The date indicated in an insurance contract as the date coverage expires at 12:00 midnight.

Explanation of Benefits (EOB)
A form sent to the enrollee after a claim for payment has been processed by the health plan. The form explains the action taken on that claim. This explanation usually includes the amount paid, the benefits available, reasons for denying payment, or the claims appeal process.

Explanation of Medicare Benefits (EOMB)
A statement detailing the amount of benefits paid or denied for services reported on a member's claim for services under the Medicare program.

Extended Care Facility
An institution devoted to providing medical, nursing or custodial care for an individual over a prolonged period of time as during the course of a chronic disease or during the rehabilitation phase after an acute illness.

Extended Medical
Coverage that supplements basic hospital and surgical medical coverage designed to cover a broad scope of extra hospital and medical costs. These costs may include provider home and office visits, prosthetics, ambulance services and hospitalization longer than the time allotted by the regular hospital plan. These benefits are usually subject to a deductible, coinsurance, lifetime maximum and out-of-pocket limits.

Elective Benefits
Lump sum payments that the insured may choose in lieu of periodic payments for certain injuries.

Eligibility Date
Date a person becomes eligible for benefits.

Eligibility Period
(1) Period of time during which potential members of a Group program may enroll without providing evidence of insurability. (2) Period of time under Major Medical policy during which reimbursable expenses may be accrued.

Eligibility Requirements
Requirements imposed for coverage eligibility, usually in a group insurance or pension plan.

Eligible Dependent
Dependent of insured person eligible for coverage according to the requirements in the contract.

Eligible Employee
Employee who is eligible based on the requirements detailed in the group contract.

Eligible Expenses
Expenses, defined in the plan, that are eligible for coverage. May involve specified health services fees or "customary and reasonable charges."

Eligible Person -Similar to eligible employee, however the contract may cover people who are not employees of a specified employer. An example might be members of an association, union, etc.

Elimination Period
The number of days of disability that must go by during a period of disability before benefits become available. Sometimes designates the probationary period, but most often states the waiting period in a Health Insurance policy.

Emergency
Injury or disease that happens suddenly and requires treatment within 24 hours.

Emergency Accident Benefit
Group medical benefit reimbursing the insured for expenses incurred for emergency treatment of accidents.

Employee Benefit Program
Benefits offered to an employee by his employer at his place of work, covering contingencies such as medical expenses, disability, retirement, and death, paid for wholly or in part by the employer. These benefits are usually insured.

Employee Certificate of Insurance
Employee's evidence of participation in a group insurance plan; a brief summary of plan benefits. The employee is provided with a certificate of insurance in lieu of the actual insurance policy.

Employee Contribution
Employee's share of premium costs.

Employer Contribution
Portion of the cost of a health insurance plan that is paid by the employer.

Enrollee
Eligible individual enrolled in a health plan; does not include eligible dependent.

Enrolling Unit
Organization (such as employer) that contracts for participation in a health insurance plan.

Evidence of Insurance
Medical exams or test required by an insurer before an applicant can purchase an individual life insurance policy.

Exclusive Provider Organization (EPO)
Preferred provider organization where individual members use specific preferred providers rather than having a choice of preferred providers. EPOs are characterized by a primary physician who monitors care and makes referrals to a network of providers.

Expected Claims
Estimated claims for a person or group for a contract year based on actuarial statistics.

Experimental or Unproven Procedures
Health care services, supplies, procedures, therapies, or devices that the health plan determines to be either (1) not proven by scientific evidence to be effective, or (2) not accepted by health care professionals as being effective.

Explanation of Benefits (EOB)
Statement sent to participant listing services, amounts paid by the plan, and total amount billed to the patient.

Extended Coverage
Provision in Health policies, usually Group, to allow the insured to receive benefits for specified losses sustained after the termination of coverage, such as maternity expense benefits incurred for a pregnancy in progress at the time of the termination.

Face Amount
The amount stated on the face of a life insurance policy to be paid in the case of death or policy maturity. It does not include dividends or additional amounts payable under accidental death or other special provisions.

Family Dependent
Person entitled to coverage because they are: 1) Enrollee's spouse, or 2) Single dependent child of either the enrollee or the enrollee's spouse (including stepchildren or legally adopted children), and 3) Resident of the enrollee's home.

Family Expense Policy
Policy insuring medical expenses of all members of a family.

Fee Maximum
Maximum amount available to a provider for health care services specified in a contract.

Fee Schedule
List of maximum fees for providers on a fee-for-service basis.

Fee-for-Service Equivalency
Difference between amount a provider receives from a reimbursement system such as capitation (a flat charge per month, for instance) compared to fee-for-service reimbursement.

Fee-for-Service Reimbursement
Health care system where physicians and providers receive payment based on billed charge for each service provided.

Field Underwriting
Initial screening "in the field" of prospective buyers of health insurance, performed by sales personnel. Also may include quoting of premium rates.

Flat Maternity Benefi
Stated benefit in a policy that is paid for maternity confinement, regardless of the actual cost of the confinement.

Flexible Benefit Plan
Program where employees tailor their benefits to meet their specific needs.

Frequency
Number of times a particular service is provided over a given time period.

Funding Level
Dollar amount required to purchase a particular program. Measured by the premium rate for an insured program, or amount assessed for expected claim loss and related fees under self-funded program.

Funding Methods
Agreed means by which an employer pays for health coverage.

Fiduciary Liability
Fiduciary liability is generally connected to coverage of pension or retirement funds. Should any wrongful act be associated with the fund, such as the mishandling of funds or acts of errors and omissions in regards to the fund, coverage would be provided. This coverage would extend to the company, its trustees, employers, fiduciaries, professional administrators of the pension fund, and also to the fund itself.

Fine Arts
Coverage provided for works of art that are damaged due to a specified loss.

Fire, Lightning, or Explosion Damage
This coverage applies when you rent your premises. It includes coverage for damage to property of others resulting from fire, lightning, or an explosion caused by you.

Flood Insurance
Flood insurance covers your building and contents in the event of a flood. For more information please see Flood.

Facility
A facility is a hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

Family Deductible
The dollar amount of the member's health benefit coverage that must be met each calendar year before payment can be made on claims. There is a maximum out-of-pocket amount that will satisfy the family deductible. Once that deductible is reached, all claims are then paid at 100% of allowable charges.

Fee For Service Payment
A payment method in which the insurer will reimburse the member or provider directly for each covered medical expense.

Fee Schedule
The fee determined by the insurer to be acceptable for a procedure or service that the physician agrees to accept as payment in full.

Formulary
See 'Drug Formulary'.

Full Time Student
A dependent enrolled at an accredited institution of learning. The student's principal residence, when not away at school, must be the same as their parents.

Generic Drug
A drug which is the pharmaceutical equivalent to one or more brand name drugs. Such generic drugs have been approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the brand name drug.

Grievance
A request to change an adverse determination that was based on administrative policies, procedures or guidelines.

Group Contract
Agreement to provide health insurance made with an employer that covers a group of persons identified by their relation to the group.

Group Number
Group specific identification number.

Gatekeeper Model
Under this model of HMO and PPO organizations, primary care physician (the gatekeeper) is the initial contact for the patient for medical care and for referrals. Also known as closed access or closed panel.

General Agent (GA)
Individual appointed by Health insurer to administer its business in a territory. Responsible for building his own agency and service force. Compensated on commission basis, although possibly has some additional expense allowances.

General LTC Rider
LTC (Long Term Care) rider attached to a life insurance policy but is independent of the life policy. The life insurance benefits are not reduced by any LTC benefits paid.

Grievance Procedure
Procedure allowing member of a health plan or provider of benefits to express complaints and seek remedies.

Group
Coverage of a number of individuals under one contract. Commonly the group is employees of the same employer.

Group Certificate
Document provided to each member of a group plan. It details benefits provided under the group contract issued to the employer or other insured.

Group Contract
Contract of insurance made with an employer or other entity covering a group of persons identified by their relationship to the entity buying the contract. Generally used to cover employees of a common employer, members of a trade association or trusteeship, members of a welfare or employee benefit association, members of a labor union, or members of a professional or other association not formed only for the purpose of obtaining insurance.

Group Disability Insurance
Coverage provided for a group for loss of compensation due to accident or sickness.

Group Model HMO
Health plan where designated group of physicians is reimbursed for services provided at a negotiated rate. HMO also contracts with hospitals for the care of patients of physicians who belong to the group.

Health Benefits Package
Coverage offered by a health plan.

Health History
Form used by underwriters to evaluate groups or individuals to determine the risk.

Health Insurance (HI)
Insurance against loss by sickness or bodily injury.

Health Maintenance Organization (HMO)
A prepaid medical service plan providing services to plan members. Providers contract with the HMO to provide medical services to members. Contracted providers must be used. Emphasis is on preventive medicine.

Health Plan
Any kind of plan covering health care services such as HMOs, insured plans, preferred provider organizations, etc.

Health Services
Benefits covered under a health contract.

Home Health Agency
Certified facility approved by health plan to provide services.

Home Health Care
Care received at home in the form of part-time skilled nursing care, speech therapy, physical or occupational therapy, part-time services of home health aides or help from homemakers or chore workers.

Hospice
Organization providing primarily pain relief, symptom management and supportive services for the terminally ill and their families.

Hospital Affiliation
Contract with one or more hospitals agreeing to provide benefits to members of a specific health plan.

Hospital Alliances
Group of hospitals working together sharing common services and thereby reducing health costs. They are better able to compete with other alliances or chains.

Hospital Benefits
Benefits payable for hospital room and board, and miscellaneous charges as a result of hospitalization.

Hospital Income Insurance
Form of insurance providing stated weekly or monthly payment during hospitalization of insured regardless of expenses incurred and whether or not other insurance is in force.

Hospital Indemnity
Coverage pays based on daily, weekly, or monthly limits regardless of the amount of actual hospital expenses.

Hospitalization Expense Policy
Policy covering daily hospital room and board charges and miscellaneous hospital expenses (such as X-ray, etc.). Often covers emergency treatment charges and may also include a surgical benefit.

Hospitalization Insurance
Form of insurance providing reimbursement within contractual limits for hospital and specific related expenses arising from hospitalization caused by injury or sickness.

Health Benefit Plan
Health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services and a provider network.

Health Insurance Portability and Accountability Act (HIPAA)
A federal act that protects people who change jobs, are self-employed or who have pre-existing medical conditions. HIPAA standardizes an approach to the continuation of healthcare benefits for individuals and members of small group health plans and establishes parity between the benefits extended to these individuals and those benefits offered to employees in large group plans. The act also contains provisions designed to ensure that prospective or current enrollees in a group health plan are not discriminated against based on health status.

Health Maintenance Organization (HMO)
An organization which provides comprehensive healthcare coverage to its members through a network of doctors, hospitals and other healthcare providers.

Healthcare Financing Administration (HCFA)
The Governmental agency responsible for administering the Medicare and Medicaid programs.

Healthcare Provider
A professionally licensed individual, facility or entity giving health-related care to patients. Physicians, hospitals, skilled nursing facilities, pharmacies, chiropractors, nurses, nurse-midwives, physical therapists, speech pathologist, laboratories, etc. are providers. All network providers are healthcare providers, but not all providers are network providers. See network provider and non-network provider.

Hearing Services
Diagnostic audiological testing that includes a wide variety of qualitative modalities not only to detect hearing loss, but also to define the nature and extent of a given deficit.

HMO
See 'Health Maintenance Organization'.

Home Health Care
Healthcare services rendered to a member in their home in lieu of confinement in a hospital or skilled nursing facility. Care must be under the supervision of a registered professional nurse. This type of care may include physical, occupation or speech therapy, medical supp