Important Health Insurance Terms & What They Mean: Part 3

The following are terminologies related to health insurance, which you are likely to come across when you file for a claim. Here is a glossary to help you understand what they mean:

1. Claim: A claim is a payment request made by the network healthcare provider to the health insurance company for services it has rendered to the policyholder in case of a cashless claim. However, in case the policyholder has paid for the healthcare services he/she has received, then a claim will be for reimbursement and submitted to the health insurance company directly by the policyholder. To know more about the types of claims, click here.
2. Case Management: Healthcare providers employ a team to handle the health insurance process. This team/health insurance desk coordinates with the policyholder prior to treatment, during treatment and post treatment to ensure that appropriate services are made available and also with the health insurance company for pre-authorisation, claim submissions, etc.
3. Date of Service: The date(s) of service refer to the date on which the policyholder availed the healthcare services for which the claim has been made.
4. Submission Date: Submission date refers to the actual date on which the claim was submitted to the insurance company.
5. Principal Diagnosis: The principal diagnosis refers to the main reason why the policyholder visited the healthcare provider in the first place and the diagnosis that lead to the treatment (for which a claim has been made).
6. Evidence of Insurability: Before treatment (during the pre-authorisation stage) or later, the health insurance company or the healthcare provider might require documentation from the policyholder as proof of his/her eligibility for the insurance.
7. Supplemental Reports: Supplemental reports refer to additional information/proof requested by the health insurance company from the healthcare provider to explain why a certain treatment was provided to the policyholder.
8. Adjudication: Adjudication is an administrative process followed by the insurance company to check the details of the claim received and to verify its authenticity and need. The insurance company also determines, through this process, whether the requested claim amount is to be fully paid, partially paid or rejected.
9. Anomalous Elements: During the adjudication process, the insurance company may find anomalies within bills for diagnosis tests, procedures, medicines or actual prescribed diagnosis/treatment path for the patient. This will affect the outcome of the claim.
10. Claim Status: Claim Status refers to the status of the claim at any given point in the process – paid, not paid, in-progress or waiting for action, etc.
11. Withhold: This refers to the amount withheld by the insurance company, in comparison to the amount requested in the claim.
12. Denied Claim: For some reason or the other, after the adjudication process, an insurance company may decide to reject the claim. This is known as  denied claim.
13. Explanation of Benefits (EOB): The health insurance company is mandatorily expected to send an EOB, a written statement explaining the reasons for the amount paid for the claim, which treatments were paid for, why certain payments were not paid as requested or why a claim was denied.
14. Appeal: If a claim has been rejected by an insurance company, the patient or healthcare provider may make a request, or appeal, that they review or change their claim decision.
15. Organisational Determination: A health insurance company, upon receiving an appeal from the healthcare provider or policyholder, reviews the claim once again. The decision then made is known as the organisational determination.

For more insurance-related terminologies and their descriptions, read Part 1 and Part 2 of the same article.