Insurance & Prior Authorization Glossary

Identify the people and plan

A health plan provides or pays for defined healthcare benefits. The member is enrolled in the plan. The subscriber is the person whose enrollment anchors coverage, while a dependent receives coverage through that relationship.

Primary insurance generally pays first under applicable coordination rules. Secondary insurance may consider remaining covered amounts. Coordination of benefits determines order when more than one plan may pay.

The CMS Uniform Glossary and health-insurance terms guide provide federal consumer orientation. Exact meanings can vary by plan and program.

Read the benefit and cost terms

A covered service is eligible for plan consideration under its terms. A coverage limitation restricts coverage by service, quantity, setting, provider, condition, age, time, or another rule. An excluded service is outside coverage under the governing source.

A premium is the amount paid for coverage. A deductible is an amount the member pays before the plan begins paying for defined services. A copayment is a fixed member amount, while coinsurance is a percentage. Cost sharing is the broader member-payment category. An out-of-pocket maximum caps defined member costs within its scope and period.

The allowed amount is the plan-recognized amount for a service under its rules. Balance billing occurs when a provider bills the patient for a difference beyond plan payment and cost sharing, where permitted. The No Surprises Act creates specified federal protections; CMS maintains provider resources. State protections may be broader.

A Good Faith Estimate is a federal estimate for specified uninsured or self-pay situations. It is different from a plan benefit quote or claim result.

Verify the network and benefit

Eligibility verification checks enrollment for a member and date. Benefit verification asks how defined services may be covered. A provider network is the contracted provider arrangement for a plan or product. An in-network provider participates under the relevant contract and effective dates.

A referral requirement may require a defined referral before service. A single-case agreement is an arrangement for a particular member or episode and does not make the provider broadly in network. Verify source, dates, services, rates, billing, and termination.

A summary of benefits and coverage summarizes plan features. It cannot answer every case-specific question.

Follow authorization as a timeline

Prior authorization is plan review required before defined care in some circumstances. HealthCare.gov says preauthorization is not a promise that a plan will cover cost.

An initial authorization addresses a first service period. Concurrent authorization reviews care while it continues. Reauthorization requests a later period. The authorization period states the dates or conditions for an approval. A unit of service is the measure the payer uses, such as a time increment, visit, day, or item.

An authorization denial refuses all or part of a request. A peer-to-peer review may be a clinician discussion, review step, or appeal-related option under a payer's process. Ask whether it pauses a deadline or preserves later rights.

Separate the claim from the clinical recommendation

A claim requests payment or reports an encounter using defined data. A diagnosis code represents diagnosis information under the applicable code set and reporting rules. It does not establish clinical need, authorization, or coverage by itself.

A claim denial is an adverse adjudication result. An explanation of benefits explains what was billed, what the plan allowed or paid, and what the member may owe. CMS's EOB guide helps families read the artifact.

Know the public-program terms

Medicaid is a joint federal-state program administered under state plans and waivers. Fee-for-service Medicaid pays through a state-administered route, while a managed care organization administers covered benefits under a managed-care contract.

The Children's Health Insurance Program covers eligible children under federal and state rules. Early and Periodic Screening, Diagnostic, and Treatment, or EPSDT, is Medicaid's child benefit framework. Medicaid explains its EPSDT scope.

A Home and Community-Based Services waiver (HCBS waiver) is a Medicaid waiver authority for eligible services and populations. It is not interchangeable with the Medicaid state-plan benefit or a commercial ABA benefit.

Use the correct complaint or review path

An adverse benefit determination is a plan decision defined by the governing process. An appeal asks for review. An internal appeal occurs within the plan, while external review involves an eligible independent review route. An expedited appeal uses a faster process when its criteria are met. HealthCare.gov provides an appeals overview.

A grievance may address service, access, conduct, quality, or another concern under plan-specific definitions. It may not substitute for an appeal of a benefit decision.

Continuity of care involves coordinated service during transitions or disruptions. A pending review does not itself extend an authorization. Ask the clinical team, payer, and provider what can continue, which risks need action, and which alternatives exist.

Find ABA care near you. Ask a Finni provider how benefits, authorization, clinical recommendations, costs, and family communication are handled for your plan.