Health Plans 101: Insurance and Medical Terms Glossary

Insurance Terms

BEHAVIORAL HEALTH

Diagnosis and treatment of mental health and substance abuse disorders

BENEFIT

The dollar amount Quartz contributes toward the payment of covered health care services

BRAND DRUG

A prescription drug that is protected by a patent, supplied by a single company, and marketed under the manufacturer’s brand name

COVERED SERVICES OR COVERED HEALTH CARE SERVICES

Specific health care services covered under a member’s health plan; covered health services include primary care services, hospitalization, outpatient care, and ambulatory and emergency care

CERTIFICATE OF COVERAGE

A document that defines services covered by a member’s health plan; this also includes essential terms, conditions affecting eligibility, and services excluded from coverage

CLAIM

A request to Quartz seeking Quartz’s payment toward the health care services covered under your health plan (You or your provider may submit a claim.)

COINSURANCE

The percentage of the charge for covered services that you have to pay after you pay the deductible

Example: If Quartz’s allowed amount for an office visit is $100 and your coinsurance is 20%:

• After you’ve paid your deductible, you pay 20% of $100, or $20. Quartz pays the rest.
• If you haven’t met your deductible, you pay the full amount of $100.

COPAYMENT

A fixed amount you pay for a covered health care service (For example, a copay of $20 means that when you go to the doctor and receive a bill that shows a cost of $130, you will only pay the fixed amount of $20 and Quartz will pay the rest.)

DEDUCTIBLE

A predetermined amount of money a member or family must pay before Quartz will make a payment toward covered services; deductibles accumulate during your benefit period (usually a year) and reset at the end of the benefit period

DEPENDENT

A person who receives health insurance through a spouse, parent, or other family member

FEE SCHEDULE

A Fee Schedule lists the maximum amount of money Quartz will reimburse a hospital or health care provider for covered services

FORMULARY

A list of prescription drugs covered by Quartz health plans; your plan documents state the Formulary that applies to your plan

GENERIC DRUG

A chemically equivalent copy designed from a brand-name drug whose patent has expired (typically less expensive and sold under the common name)

HMO (HEALTH MAINTENANCE ORGANIZATION)

A form of health insurance in which members prepay a premium for health services and which generally includes a defined set of services made available through a defined panel of physicians at a preset price

 HSA (HEALTH SAVINGS ACCOUNT)

A tax-advantaged way to save money for health care expenses; members can establish an HSA when they have a High Deductible Health Plan (HDHP)

MEMBER

A person enrolled in a Quartz health plan.

NETWORK

A group of providers that have a contract with Quartz; Quartz contracts with health care providers to obtain lower prices for our members (By building a network of high-performing health care providers, Quartz seeks to make the best care available to our members at the lowest price.)

NURSE PRACTITIONER (NP)

Nurses who are specially trained to assume an expanded role in providing medical care under the supervision of a physician; NPs cannot serve as a PCP for Quartz members, but are available for routine exams, urgent/problems visits, and follow-up care

OUT-OF-POCKET COSTS

Your expenses for medical care that are not paid by insurance; out-of-pocket costs include deductibles, coinsurance, and copayments for covered services, plus all costs for services that aren’t covered

PARTICIPANT

A person who participates in the health benefit plan offered by their employer/plan sponsor

POS (POINT OF SERVICE)

A managed care plan that offers coverage In-Network and Out-of-Network; members pay lower out-of-pocket costs when they receive care from In-Network providers

PPO (PREFERRED PROVIDER ORGANIZATION)

A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of providers; you pay less if you use providers that belong to Quartz’s network (You can use doctors, hospitals, and providers outside of the network for an additional cost.)

PRACTITIONER

A person who supplies health care services (i.e., physician, psychologist, nurse practitioner)

PRIOR AUTHORIZATION

A request for Prior Authorization is submitted by members and providers; Quartz reviews the request and responds by letting the member and provider know whether the service, treatment, or supply is covered under the member’s plan

PROVIDER

A person or entity that supplies health care services (For example, providers include pharmacies, hospitals, or other health care facilities that provide services to members.)

SCHEDULE OF BENEFITS (SOB)/SUMMARY OF BENEFITS AND COVERAGE (SBC)

An easy-to-read summary that shows health care services you may need and the benefit Quartz contributes toward paying the cost of those health care services

SUMMARY PLAN DESCRIPTION (SPD)

An easy-to-read summary that shows health care services you may need and the benefit your employer contributes toward paying the cost of those health care services

SUBSCRIBER

The person in whose name a health insurance certificate or insurance policy is held.

USUAL, CUSTOMARY, AND REASONABLE (UCR)

The amount covered by Quartz based upon the customary charges of all providers within a given geographic area for the same or similar health care service

Medical Terms

ALLERGY AND IMMUNOLOGY

Diagnosis and treatment of allergic conditions and diseases of the immune system

ANESTHESIOLOGY

Administration of anesthesia to achieve temporary, partial, or complete loss of sensation to a patient undergoing surgery

AUDIOLOGY AND SPEECH – LANGUAGE PATHOLOGY

Diagnosis and treatment of hearing, speech, and language disorders

BEHAVIORAL HEALTH

Diagnosis and treatment of mental or behavioral health problems such as depression, eating disorders, substance abuse, or anxiety disorders; practitioner types include psychiatrists, psychologists, and counselors

CNM (CERTIFIED NURSE MIDWIFE)

A person who assists women in childbirth

CNP (CERTIFIED NURSE PRACTITIONER)

Nurses who are specially trained to assume an expanded role in providing medical care under the supervision of a physician

CANCER

See Oncology, Medical Oncology, Gynecologic Oncology, and Radiation Oncology

CARDIOLOGY OR CARDIOVASCULAR DISEASE

Diagnosis and treatment of diseases of the heart and blood vessels

CHIROPRACTIC

Treatment that utilizes the relationship between the musculoskeletal structures and functions of the body, particularly of the spinal column and the nervous system

CRITICAL CARE MEDICINE

Health care provided to a critically ill patient during a medical emergency or crisis

DC (DOCTOR OF CHIROPRACTIC)

See Chiropractic

DDS (DOCTOR OF DENTAL SURGERY)

See Dentistry

DO (DOCTOR OF OSTEOPATHY)

Diagnoses and treats diseases, injuries, and disorders for people of all ages; a physician who has had four years of premedical education in a college or university followed by four years of medical school (education includes training in musculoskeletal manipulation)

DPM (DOCTOR OF PODIATRIC MEDICINE)

See Podiatry

DENTISTRY

Care and treatment of the teeth and gums

DERMATOLOGY

Diagnosis and treatment of diseases and disorders of the skin

ENDOCRINOLOGY, DIABETES, AND METABOLISM

Diagnosis and treatment of diseases and disorders of the endocrine glands (thyroid, pituitary, pancreas, ovaries, and testes), including diabetes

ENT (EAR, NOSE, AND THROAT)

See Otolaryngology

FAMILY PRACTICE

Medical Doctors who diagnose and treat medical conditions for people of all ages, with an emphasis on family health problems

GASTROENTEROLOGY

Diagnosis and treatment of diseases and disorders of the stomach, intestines, liver, and gallbladder

GENERAL PRACTICE (GP)

Medical Doctors who diagnose and treat diseases, injuries, and disorders for people of all ages

GERIATRIC MEDICINE

Diagnosis and treatment of medical conditions in the elderly

GERIATRIC PHYSICIAN (GER)

Medical Doctor providing comprehensive diagnosis, evaluation, and care for elderly individuals

GYNECOLOGIC ONCOLOGY

Diagnosis and treatment of cancers of the female reproductive organs, such as ovarian cancer, cervical cancer, and uterine cancer

HEMATOLOGY

The treatment of diseases of the blood, spleen, and lymph glands

INFECTIOUS DISEASE

Diagnosis and treatment of complicated infections, including those associated with patients with reduced abilities of the immune system such as leukemia patients, organ transplant recipients, and HIV-related diseases

INTERNAL MEDICINE (IM)

Medical Doctors who diagnose and treat diseases and disorders of the body for people over age 18; includes basic and preventive treatment and diagnosis, and treatment of acute and chronic illnesses

MD (MEDICAL DOCTOR)

Physician who has had four years of premedical education in a college or university followed by four years of medical school

MATERNAL AND FETAL MEDICINE

Treatment for patients with complicated pregnancy.

MEDICAL ONCOLOGY

Diagnosis and treatment of the abnormal growth of tissue (cancer)

NEONATAL ONCOLOGY

Care for high-risk infants, including pre-term and full-term infants with medical or surgical problems

NEPHROLOGY

Diagnosis and treatment of diseases and disorders of the kidneys

NEUROLOGY

Diagnosis and treatment of diseases and disorders of the nervous system

NEUROSURGERY

Surgical treatment of disorders and injuries of the brain and nervous system.

NP (NURSE PRACTITIONER)

Nurses who are specially trained to assume an expanded role in providing medical care under the supervision of a physician

NUTRITION

Treatment of various types of nutritional problems, such as obesity, nutrition support, and malnutrition; see providers under Endocrinology, Diabetes, and Metabolism, and Internal Medicine.

OD (DOCTOR OF OPTOMETRY)

See Optometry

OBSTETRICS AND GYNECOLOGY (OB/GYN)

Medical Doctors who diagnose and treat females and the female reproductive system, including management of care during pregnancy and childbirth

OCCUPATIONAL MEDICINE

Management of medical conditions in relation to motor skills

OCCUPATIONAL THERAPY

Use of therapeutic activities in mental and physical disorders

ONCOLOGY

Diagnosis and treatment of tumors and cancer; see Medical Oncology, Gynecologic Oncology, and Radiation Oncology.

OPHTHALMOLOGY

Examination, diagnosis, treatment, and management of diseases and disorders of the eye with appropriate medical and surgical procedures

OPTOMETRY

​​Examination, diagnosis, treatment, and management of diseases and disorders of the eye and visual system

ORAL AND MAXILLOFACIAL SURGERY

Surgery to treat disorders of the gums, teeth, and mouth

ORTHODONTICS

The use of devices (such as braces) to move teeth or adjust underlying bone

ORTHOPEDIC SURGERY

Diagnosis, treatment, and repair of disorders involving the spine, bones, joints, and muscles

OTOLARYNGOLOGY OR EAR, NOSE, AND THROAT (ENT)

Diagnosis and treatment of diseases and disorders of the ear, nose, and throat

PEDIATRICIAN (PEDS)

Medical Doctors who diagnose and treat infants and children up to age 18

PEDIATRICS

Diagnosis and treatment of diseases of children and adolescents and general management of their health

PHYSICAL MEDICINE AND REHABILITATION

Therapeutic use of physical medicine and equipment in the treatment of injury and disease

PHYSICAL THERAPY

The use of exercise and physical activities to condition muscle and improve a patient’s level of activity

PHYSICIAN ASSISTANT (PA) OR PHYSICIAN ASSISTANT – CERTIFIED (PA-C)

A health care professional who is licensed to provide patient education or evaluation and health care services; a physician assistant works under the supervision of a doctor to provide medical care

PLASTIC SURGERY

Repair and restoration of external physical defects or trauma effects

PSYCHIATRY/PSYCHOLOGY

Diagnosis and treatment of mental, addictive, and emotional disorders; see Behavioral Health

PODIATRY

Diagnosis and treatment of diseases and injuries to the foot

PULMONARY DISEASE AND PULMONOLOGY

Diagnosis and treatment of diseases of the lungs and airways

RADIATION ONCOLOGY

Medical use of radiation to destroy cancers

RN (REGISTERED NURSE)

An individual trained to provide medical care under the supervision of a physician

RHEUMATOLOGY

Diagnosis and treatment of diseases and disorders of the joints, muscles, bones, and tendons, such as arthritis and degenerative joint disease

SPECIALIST

Physician who has had four years of premedical education in a college or university followed by four years of medical school, plus at least three years of residency in a specific area of medicine

SPORTS MEDICINE

Diagnosis and treatment of sports-related injuries with emphasis on prevention of injury and illness

SURGERY

Operative treatment of internal and external diseases

THORACIC SURGERY

Use of surgery to treat diseases of the heart and lungs

UROLOGY

Diagnosis and treatment of diseases and disorders of the urinary system and adrenal glands

VASCULAR SURGERY

Use of surgery to treat diseases of the blood vessels, including stroke and circulation problems