WORDS TO KNOW – Glossary of Terms:

For a detailed glossary of health insurance and parity terms, visit: https://www.paritytrack.org/know-your-rights/glossary/ )

Adverse benefit determination

This is a fancy title for a denial — a decision by your insurance company to deny or reduce payment for a particular medical service, or to terminate your health insurance coverage.

Appeal

When a person challenges an insurance claim that has been denied. Usually, each insurance company has its own process.

Arbitration

A process to settle conflicts or disputes without having to go to court. Arbitration is an option in some insurance plans if your plan denies coverage for your behavioral health care.

Claim

A request for treatment or service.  Your claim file includes all of the information and documents involved in an insurer’s review of a requested treatment or service. You have a right to review your full claim file at no cost to you.

Classification of Benefits

Federal parity regulations created six different categories of insurance benefits for all behavioral health services: inpatient in-network , inpatient out-of-network , outpatient in-network , outpatient out-of-network , emergency care, and prescription drugs. All services fall into one of these categories.

Disclosure

Information an insurer has to tell you about your plan and what rules and laws apply to your plan.

Exclusions

Specific services an insurance plan will not cover.

External Review

One of the last steps in the appeal process.  A person may ask for an external review once she has completed all of the insurance plan’s appeal processes. Usually a group of people that aren’t part of the insurance company will review everything and decide whether or not the insurance company must pay for treatment. External reviews are usually done by an Independent Review Organization

Medical Necessity

A set of standards health insurance companies use to decide if they will pay for health care services. A service meets these standards if it’s considered an accepted treatment for the specific diagnosis and it’s the least expensive option that will help the person recover.  Medical necessity is the most commonly used reason by insurers to deny mental health and addiction services and treatment.

Medically Necessary

Any health-care services or prescription medications that are needed to treat a condition and that meet accepted standards of medicine. This is closely related to medical necessity.

Step Therapy / Fail-First Protocol

A requirement that a patient try a less expensive treatment first before she can get approval for the treatment her provider orders. For example, an insurance plan may not pay for a brand name medication until a person does not improve using a generic medication.

Utilization Review

The way an insurance company decides if health care services are medically necessary, appropriate, and accepted medical practices. Utilization management is also called “medical review” or “utilization review.” There are three different kinds: 1) Concurrent: This review happens during the treatment. 2) Prior: This type of review happens before the treatment happens. It’s also called prior authorization. 3) Retrospective: This type of review happens after the treatment happens.