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Medical Insurance: N-Q


Network - a company that serves as an intermediary between providers and insurance carriers. The network specifies the reimbursement rates for specific services that the provider agrees to accept. The network contracts with the insurance carrier that these providers will accept these specific rates.


Open Enrollment - the time period that an employer designates for employees to review and research benefit options available.


Paper claims - the paper process that anyone can use to mail claims to an insurance administrator in order to receive payment, or reimbursement of payment, for services rendered.

PAR, Participating - a provider who is a member of a network, also known as in-network.

Payment - the amount sent to the provider for services rendered, or the amount sent to the member for reimbursement of payment for services.

Payroll Deduction - an amount deducted from an employee's paycheck on a predetermined schedule to contribute to the employee's portion of payment required for different benefits.

PCP, Primary Care Physician - the family doctor, the doctor who is allowed to refer treatment to a specialist.

PHI, Personal Health Information - information about a patient's coverage and treatment.

Phone Tree - the options and prompts you will hear when dialing the number for Customer Service.

PPO, Preferred Provider Organization - a network of providers contracted with an insurance program to provide services for a specific amount. The individual being treated usually must pay a deductible or coinsurance for the treatment.

Preauthorization - medical records requested by the insurance administrator to justify the need for a particular service. Also known as predetermination.

Predetermination - medical records requested by the insurance administrator to justify the need for a particular service. Also known as preauthorization.

Pre-Existing Condition - any recent or on-going disease or injury requiring supervision by a doctor.

Preferred Prescriptions - Either a lower cost brand name medication, or a high cost brand name medication.

Preventive Care - services that screen patients for possible symptoms relating to known diseases that can lead to premature death. Also known as Routine Physicals, Annual Exams, and Wellness Check-Ups.

Primary Coverage - the insurance policy determined to pay first.


QME, Qualified Medical Expenses - medical expenses, as determined by the Internal Revenue Service, that are eligible to included as deductions from income when filing Federal Taxes.

Qualifying Life Event - a change to your family situation that is enables you to make eligibility changes to your policy outside of the open enrollment period.