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Glossary

Accreditation:

Certification that an organization meets certain standards. Examples: accreditation of HMOs by the National Committee for Quality Assurance (NCQA) or accreditation of hospitals by the Joint Commission of Accreditation of Healthcare Organizations (JCAHO).

Adjudication:

The administrative procedure used to process a claim for services according to the covered benefit.

Administrative services contract (ASC):

An arrangement in which a licensed insurer provides administrative services to an employer's health benefits plan (such as processing claims), but doesn't insure the risk of paying benefits to enrollees. In an ASC arrangement, the employer pays for the health benefits.

Allowable charge:

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

Ambulatory care:

A general term for care that doesn't involve admission to an inpatient hospital bed. Visits to a doctor's office are a type of ambulatory care.

Ambulatory surgery:

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

American Dental Association (ADA):

A professional association of dentists dedicated to serving the public and profession of dentistry.

American Medical Association (AMA):

A professional association of physicians dedicated to promoting the art and science of medicine and the betterment of public health.

Ancillary care:

Diagnostic and/or supportive services such as radiology, physical therapy, pharmacy or laboratory work.

Anniversary date:

The day after a coverage period ends under a health benefits plan. Usually, the month and day that a health benefits plan first goes into effect becomes its anniversary date each year.

Appeals:

A process available to the patient, their family member, treating provider, or authorized representative to request reconsideration of a previous adverse determination.

Authorization:

Approval of services benefits before they are obtained. See also "prior authorization" for medications.