Health / Health Insurance Glossary

Covered Expenses: An amount customarily charged for or covered for similar services and supplies which are medically necessary, recommended by a doctor, or required for treatment.

Credentialing: The process of obtaining, reviewing, and verifying a provider's credentials—the documentation related to licenses, certifications, training, and other qualifications—for the purpose of deter . . . View Full Definition

Credentialing Committee: Committee, which may be a subset of the QM committee, that oversees the credentialing process.

Credibility: A measure of the statistical predictability of a group's experience.

Credit For Prior Coverage: This is something that may or may not apply when you switch employers or insurance plans. A pre-existing condition waiting period met under while you were under an employer's (qualifying) co . . . View Full Definition

Cure Provision: A provider contract clause which specifies a time period (usually 60--90 days) for a party that breaches the contract to remedy the problem and avoid termination of the contract.

Deductible: A flat amount a group member must pay before the insurer will make any benefit payments.

Demand Management: The use of strategies designed to reduce the overall demand for and use of healthcare services, including any benefit offered by a plan that encourages preventive care, wellness, member self . . . View Full Definition

Denial Of Claim: Refusal by an insurance company or carrier to honor a request by an individual (or his or her provider) to pay for health care services obtained from a health care professional.

Dental Health Maintenance Organization (DHMO): An organization that provides dental services through a network of providers to its members in exchange for some form of prepayment.

Dental Point Of Service (Dental POS) Option: A dental service plan that allows a member to use either a DHMO network dentist or to seek care from a dentist not in the HMO network. Members choose in-network care or out-of-network care a . . . View Full Definition

Dental Preferred Provider Organization (Dental PPO): An organization that provides dental care to its members through a network of dentists who offer discounted fees to the plan members.

Dependent Worker: A worker in a family in which someone else has greater personal income.

Dependents: Spouse and/or unmarried children (whether natural, adopted or step) of an insured.

Diagnostic And Treatment Codes: Special codes that consist of a brief, specific description of each diagnosis or treatment and a number used to identify each diagnosis and treatment.

Disease Management (DM): 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 specifi . . . View Full Definition

Drive Time: A measure of geographic accessibility determined by how long members in the plan's service area have to drive to reach a primary care provider.

Drug Utilization Review (DUR): A review program that evaluates whether drugs are being used safely, effectively, and appropriately.

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