Healthcare Glossary

Key healthcare terms

A

Abrasion
Wearing away of enamel on teeth. This may be caused by normal grinding, friction or incorrect brushing of teeth.
Abutment or retainer crown
This is an artificial crown that supports a dental device used to replace a missing tooth.
Abutments
This refers to attachments on the ends of a bridge, which are cemented to the natural teeth or a tooth used for support or anchorage of a fixed or removable prosthesis.
Accelerated death benefit
This rider provides early access to life insurance benefits in case of a terminal illness. Living benefits are paid to the insured for medical expenses before death. Benefits paid decrease the benefit payable to beneficiaries after the insured's death
Accepting assignment
Accepting Assignment refers to those instances when a provider agrees to accept the TRICARE allowable charge(s).
Access
Access refers to your ability to obtain medical care.
Access fee
This is a fee you pay directly to a provider for a service related to treatment covered by your insurance provider.Some HumanaOne plans have access fees for specific services. These fees are separate from deductibles, coinsurance, or copayment charges. For example, there is an emergency room access fee that must be paid each time you visit an ER. The emergency room access fee is waived if you're admitted to the hospital.
Accidental death benefit rider
An additional cash benefit paid in addition to other benefits when a death is a result of an accident.
Account
For spending accounts, this term refers to the particular type of account (FSA, PCA, or HSA) the subscriber participates in.
Account termination date
The date a spending account was closed.
Accumulation period
Length of time an individual has to incur covered expenses to satisfy a required deductible and/or calendar year or plan year maximum.
Actively-at-work provision
Life insurance coverage is not available to employees who are not actively at work on the effective date of the employer's contract with Humana; employees are covered when they return to work.
Actual charge
The amount of money a doctor or supplier charges for a specific medical service or supply is the actual charge. This is often higher than the approved amount that you and Medicare pay because Medicare and insurance companies negotiate lower rates for members.
ADApt
Concentra’s proprietary program, ADApt defines essential job functions for employers. It’s typically used for pre-placement and return-to-work programs within the clinic.
Adjudication
Processing a claim to determine proper payment is referred to as adjudication.
Admission
This refers to your entry into a medical facility as a registered inpatient according to the rules and regulations of that facility. Your admission ends when you are discharged or released from the facility.
Admitting physician
The doctor responsible for admitting you into a hospital or other inpatient health facility is referred to as the admitting physician.
Advance coverage decision
This is a decision on whether a specific service is covered under your Private Fee-for-Service Plan.
Advanced imaging
Advanced imaging refers to radiology tests that use complex, highly developed, non-invasive technology to view the interior of the body. Examples include CT scans, ultrasound, MRA, and MRI tests.
Advanced Toxicology Network (ATN)
This is Concentra’s drug-screen laboratory located in Memphis, Tennessee.
Age in
When a retiree or eligible dependent becomes Medicare eligible — usually after turning 65 — and is eligible to enroll in the group sponsored Medicare Advantage plan.
Age limit
The minimum and maximum ages for applicants looking to enroll or renew benefits with an insurance company is also known as age limit.
Allowable charges
Allowable charges are the maximum amount a benefits plan will pay for a procedure.
Alveolectomy
Removal of excessive bone and soft tissues, usually done to enhance the fit or appearance of an artificial denture.
Amalgam
Metallic filling made by combining an alloy of silver, zinc, lead, and tin with mercury. It is silver in color.
Ambulatory care
Any health service that does not require an overnight hospital stay is considered ambulatory care.
Ambulatory surgical center
Also known as an “in-and-out” center, this is a non-hospital location where outpatient surgery is performed. You might stay at an ambulatory surgical center for a few hours after surgery or up to one night following the procedure.
Americans with Disabilities Act (ADA)
This 1990 federal law prohibits discrimination against people who are disabled and formally describes "disability."
Amount charged
The amount billed for a specific service.
Amount repaid
On the Expenses Requiring Verification Table, this is the amount deposited back into your spending account because you sent repayment for a non-qualified expense.
Analgesia
Analgesia is the reduction or elimination of pain.
Anatomical crown
This is the portion of your tooth that is normally covered by and which includes the tooth’s enamel.
Ancillary services
Services, other than those a provider performs, are ancillary services. These might include laboratory work, X-rays, and anesthesia.
Anesthesia
See General Anesthesia, Intravenous Sedation / Analgesia, Local Anesthesia, Non-Intravenous Conscious Sedation, or Regional Anesthesia.
Annual deductible
The amount of covered expenses you must pay in one year before your insurance plan pays any benefits is your annual deductible. For Medicare Part B, Medicare begins to pay 100% of certain covered expenses as soon as you have met the deductible for the year. For Medicare Part A, deductibles are not based on an annual cycle but on individual benefit periods. See the definitions for benefit period, Medicare Part A, and Medicare Part B.
Annual election
The total amount of FSA or PCA funds the employee selects for the plan year. In some cases, the employer determines the FSA or PCA amount.
Annual election period
You can enroll in Medicare for the first time whenever you become eligible. To change your coverage, though, you need to wait for the annual election period, which runs from October 15 through December 7 of each year. This is when you can join a Medicare Advantage health plan or prescription drug plan. You can enroll in Medicare Supplement plans, however, at any time if you meet the eligibility requirements. See the definition for Medicare Supplement insurance.
Annual maximum
The total amount you'll spend between your plan effective date and the end of your plan year.
Annual maximum benefit
Maximum dollar amount paid by the dental plan in a calendar year or plan year.
Annual Notice of Change (ANOC)
Centers for Medicare & Medicaid Services -mandated notification of yearly plan benefit changes that is sent to enrolled members.
Annual plan premium
This is the total amount you pay for a Humana Medicare plan during the calendar year.
Anterior teeth
The front teeth six upper and six lower.
Apicoectomy
Apicoectomy refers to cutting off the root end of a tooth.
Appeal (Individual & Family)
An appeal is a written request from the enrolled member or the enrolled member's authorized representative, a non-network provider, or court- appointed guardian to reconsider our initial adverse determination to deny coverage of service or payment of a claim, including delay in providing, arranging or approving the healthcare service.
Appeal (Medicare)
You can file an appeal if you were denied a request for healthcare services or payment for services you already received. You can also appeal if you disagree with a decision to stop services you are receiving. Medicare Advantage and Medicare prescription drug plan carriers as well as Medicare Parts A and B must follow a specific process when you ask for an appeal.
Application
You must submit a to a signed application to an insurance company to be considered for a policy.
Applied reserve
The amount of Coordination of Benefits (COB) savings from prior claims applied to pay allowable expenses on subsequent claims. This amount is not otherwise paid by the primary other insurance and regular plan benefits.
Approved amount
The approved amount is the fee Medicare sets as reasonable for a covered medical service. This is the amount you and Medicare pay for a service or supply. The amount may be less than the actual amount charged by a doctor or supplier. The approved amount is sometimes called the approved charge.
Arch
Arrangement of the teeth in a bow shape or arc is an arch.
Artificial crown
This is a crown that covers or replaces most or all of the anatomical crown of a tooth
Assignment
In Medicare Parts A and B, assignment means a doctor agrees to accept Medicare's approved amount as full payment. You can save money by going to a doctor who accepts assignment, but you may still have some costs, such as coinsurance. See the definitions for actual charge, approved amount, and coinsurance.
Assignment of benefits
This is an arrangement by which you request that your health benefit payments be made directly to a designated person or facility, such as a doctor or hospital.
Assisted living
This is a living arrangement in which you are assisted with everyday life activities and receive personal care services such as meals, housekeeping, and transportation. This assistance is offered, as needed, to people who still live on their own in a residential facility. In most cases, assisted living residents pay regular monthly rent plus fees for additional services they receive.
Attending physician
Your attending physician is the licensed doctor who has primary responsibility for your medical care and treatment.
Authorization
You must have a verbal or written authorization from your insurance plan for some services before you receive care.
Authorization for care
This refers to the determination that the requested treatment is medically necessary, delivered in the appropriate setting, a TRICARE benefit, and that the treatment will be cost-shared by the Department of Defense.
Available balance
The amount of funds in your spending account you can use for eligible expenses.

B

Baby teeth
Primary or deciduous teeth of young children: 10 upper and 10 lower.
Balance billing
In balanced billing, you may be billed the difference between what your insurer pays and the fee your provider normally charges.
Base Realignment and Closure Commission (BRAC) site
A military base that has been closed or targeted for closure by the government BRAC.
Basic services
Dental procedures to repair and restore individual teeth due to decay, trauma, impaired function, attrition, abrasion or erosion, basic services may include endodontics (root canals), fillings and periodontics (tissue/bone treatment).
Beneficiary
The person who is eligible to receive or is receiving benefits under an insurance certificate. This person is named by the certificate owner, who is usually the person insured
Beneficiary (Medicare)
The beneficiary is the person who has health insurance through the Medicare or Medicaid program.
Beneficiary (TRICARE)
A beneficiary is a person who is eligible for TRICARE benefits. Beneficiaries include Active Duty Family Members (ADFMs) and retired service members and their families. Family members include spouses and unmarried children, adopted children, or stepchildren up to the age of 21 (or 23 if full-time student at approved institutions of higher learning and the sponsor provides more than 50% of the financial support). Other beneficiary categories are listed in the TRICARE Eligibility section of your handbook.
Beneficiary Counseling and Assistance Coordinators (BCACs)
BCACs are persons at Military Treatment Facilities (MTFs) and TRICARE Regional Offices who are available to answer questions, help solve health care-related problems, and assist beneficiaries in obtaining medical care through TRICARE. BCACs were previously known as Health Benefits Advisors (HBAs). To locate a BCAC, visit the TRICARE BCAC/DCAO Directory.
Benefit accumulations
Amount that has been paid for a covered person during the calendar year or plan year.
Benefit booklet
This is a booklet or pamphlet you receive once you enroll in HumanaDental. It contains a general explanation of the benefits. It is also known as Summary Plan Descriptions.
Benefit period
Benefit period refers to time during which you are admitted and treated at a hospital or skilled nursing facility. The benefit period begins the day you go to the facility and ends when you have not received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins.
Benefit plan
A benefit plan covers costs associated with certain dental services. In addition to paying premiums for your benefits, you may be responsible for deductibles, coinsurance, and/or maximums.
Benefit plan document
Generic term for a legal document detailing a member's or group's coverage. This document usually is referred to as a Certificate of Coverage, Certificate of Insurance, or Summary Plan Description.
Benefit summary
A brief description or outline of your plan’s coverage, your benefit summary includes the amounts or percentage you pay for certain services, the amounts or percentage your plan pays, and the services for which coverage is limited or excluded.
Benefits
This is the medical — also dental and pharmacy — care for you and your dependents that's covered by your insurance either directly or through reimbursement.
Benefits (Medicare)
Medicare-approved services provided by an insurance policy are known as benefits. In a health plan, benefits are the coverage amounts for healthcare services you receive, such as doctor’s office visits.
Benefits maximum
This is the highest dollar amount your health plan will pay toward your medical costs over the course of a plan year.
Benefits summary
This refers to a detailed summary of all the benefits available in your plan.
Bicuspid
Permanent teeth between the cuspids (canines) and first molars, bicuspids have two cusps (points) and are used for crushing and tearing food.
Bilateral
This refers to both the right and left sides.
Billed claims
This is the amount providers bill for the services they provide.
Billing provider
Any eligible person, doctor, doctor's office, hospital, dentist, or facility licensed to perform services for our members.
Bitewing X-ray
A bitewing X-ray reveals the crown and the adjacent tissue of the upper and lower jaws on the same film. It is used to detect decayed areas between teeth.
Bitewings
A bitewing is a type of X-ray in which you bite down on X-ray film to allow a dentist to capture images of several upper and lower teeth at one time.
Bleaching
For dental care, this is a technique used to restore a discolored tooth to its natural color.
Board certified
A physician who has graduated from medical school, completed residency, trained under supervision in a specialty, and passed a qualifying exam given by a medical specialty board is considered board certified.
Bonding
Bonding is white dental material that is applied to a tooth to change its shape and/or color. Bonding also refers to how a filling or some bridges are attached to teeth.
Braces
These are metallic bands and appliances used to move teeth for correction of the bite and tooth position.
Bridge
Appliance to replace a missing tooth or teeth, attached to and supported by abutment teeth.
Bruxism
Grinding of teeth during sleep. This occurs in children and adults, and causes abrasion of the tooth enamel.
Buccal surface
Surface of the back teeth next to the cheek.

C

Calendar year
The 12-month period that begins on January 1 and ends on December 31 is the calendar year. When you enroll in Medicare, coverage begins on the effective date of your policy and ends on the following December 31.
Canal
Space within the root of the tooth that contains the pulp tissue.
Canine
The pointed tooth used to tear food is the canine.
Cap
See Crown.
Capitation
Method of payment for health services in which a dentist or specialist is paid a fixed amount for each person served regardless of the number or nature of services provided to each person. Capitation is usually associated with a prepaid/HMO plan.
Caries
Decaying of teeth. Also known as cavities.
Carve out
See Nonduplication of Benefits.
Catastrophic cap
This is the maximum out-of-pocket expenses for which TRICARE beneficiaries are responsible in a given fiscal year (October 1 to September 30). Point-Of-Service (POS) cost-shares and the POS deductible are not applied to the catastrophic cap.
Catastrophic coverage
Offered with Medicare Part D, catastrophic coverage is designed to prevent you from having to pay very high out-of-pocket expenses. Once you have spent a pre-determined amount on your healthcare within a year, you will pay no more than 5% for each prescription drug. You will still need to pay your monthly premiums for the plan.
Catastrophic illness
A catastrophic illness is a very serious and costly health problem that could be life threatening or cause life-long disability. The cost of medical services for this type of condition could cause you financial hardship if you are not properly insured.
Catchment area
This refers to geographic areas determined by the Assistant Secretary of Defense (Health Affairs) that are defined by a set of five-digit ZIP codes, usually within an approximate 40-mile radius of a military inpatient treatment facility.
Cavities
Cavities are decaying teeth (also known as caries).
Cavity
Another term for tooth decay. See Caries.
CDC
The Centers for Disease Control and Prevention is an agency of the federal Department of Health and Human Services.
Cementation
This refers to affixing an inlay, onlay, crown, or bridge with a dental cement.
Center Operations Director (COD)
The COD is the head administrative employee in a Concentra medical center.
Centers for Medicare & Medicaid Services (CMS)
The primary governing entity for the Medicare Advantage Program, CMS was formerly known as the Healthcare Financing Administration (HCFA). All materials, forms, letters, attachments, etc., that are distributed to retirees by the Medicare Advantage plan must be submitted to CMS.
Centers for Medicare and Medicaid Services (CMS)
This federal agency runs the Medicare program. In addition, CMS works with states to run the Medicaid program. CMS works to make sure that beneficiaries in these programs are able to get high-quality healthcare.
Certain requirements
To be eligible for a Medicare Supplement plan, you must have Medicare Part A and Part B. You have the right to buy a Medicare Supplement policy if you are in your Medicare Supplement Open Enrollment Period or covered under a protection. Your Medicare Supplement Open Enrollment Period, for Medicare Supplement plans, lasts six months. It starts on the first day of the month in which you are BOTH age 65 or older AND enrolled in Medicare Part B. Once your Medicare Supplement Open Enrollment Period starts it cannot be changed. Federal law doesn’t require insurance companies to sell Medicare Supplement policies to those under age 65. However, some states may require insurance companies to sell you a Medicare Supplement policy, even if you are under age 65. To find out more, check with your state insurance department.
Certificate of coverage
A description of the benefits included in a benefit insurer's plan, the certificate of coverage is required by state law and explains the coverage provided under the contract.
Certificate of Coverage
Legal document detailing a member's or group's coverage.
Certificate of insurance
This certificate serves as proof of insurance and outlines benefits and provisions.
Certificate of Insurance
Legal document detailing a member's or group's coverage.
CHAMPUS Maximum Allowable Charge (CMAC)
CMAC is a nationally determined allowable charge level that is adjusted by locality indices and is equal to or greater than the Medicare Fee Scheduled amount. CMAC is the TRICARE-allowable charge for covered services when appropriately applied to services priced under CMAC.
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
The health care program established to provide purchased health care coverage for ADFMs and retired service members and their family members outside the military’s direct care system. TRICARE Management Activity was organized as a separate office under the Assistant Secretary of Defense and replaced CHAMPUS in 1994. The purchased care benefits authorized under the CHAMPUS law and regulations are now covered under TRICARE Standard.
Claim
A claim is information submitted by a provider or covered person for reimbursement for services or materials.
Claim (Medicare)
A claim is a request for payment (also called a bill) for services and benefits you have received. Medicare Part A and Part B services are billed through private insurance companies. Bills from private insurance companies for Part B physician/supplier services are sometimes also referred to as claims. See definitions for Medicare Part A and Medicare Part B.
Claim ID
The number that uniquely identifies the claim Customer Care can use this number to track your claim if you have questions.
Claim number
A number assigned by Humana to identify a claim internally.
Claim status
The amount of Coordination of Benefits (COB) savings from prior claims applied to pay allowable expenses on subsequent claims. This amount is not otherwise paid by the primary other insurance and regular plan benefits.
Claim type
On the spending account Claim Form, this is the type of expense incurred, such as a healthcare expense for you, a spouse, or a dependent.
Claims review
Review of a claim is done before reimbursement is submitted to the provider or subscriber.
Cleft lip
A congenital facial deformity, this is characterized by non-fusion or malfusion of the tissue that makes up the lips.
Clinical crown
This is the portion of a tooth not covered by supporting tissues.
Clinicians
Physicians, therapists, mid-level practitioners, nurses, and other medical professionals who provide care to patients in the clinic setting are known as clinicians.
Closed panel
With a closed panel, you can only receive benefits if services are performed by providers who have signed an agreement with Humana to provide treatment to eligible patients.
COBRA
This law requires employers to offer continued benefits coverage to employees who have had their benefits terminated.
Coinsurance
Coinsurance is a set percentage of the total cost of your care. For example, if you have an 80 percent benefit after the deducible, it means Humana will pay 80 percent of covered costs after your deductible is satisfied. You pay the remaining 20 percent. When two coinsurance levels are shown - for instance, 80/60 - the first number is for in-network providers and the second number is for out-of-network providers. When you use an in-network provider, your coinsurance is based on the discounted price for Humana members, which may be less than the original charge. Sometimes, you may be required to pay a copayment, deductible, and coinsurance for a particular service. Please consult your Certificate of Coverage for your specific copayment, deductible, and coinsurance amounts.
Colleague(s)
Concentra’s term for employee(s), the term colleague emphasizes the professionalism of Concentra’s work and recognizes the inter-relationships with management, peers, customers, patients, and associates.
Collection
In the drug-screen context, collection is the gathering of a patient’s urine, blood, or hair for laboratory testing.
Completed
Refers to the stage of benefits processing when HumanaDental has received an estimate or claim and has released an explanation of benefits or explanation of remittance.
Composite
For dental care, this is a white plastic filling material of resin and quartz crystals.
Comprehensive Outpatient Rehabilitation Facility (CORF)
A CORF facility provides a full range of rehabilitation services to outpatients with physical disabilities. A physician supervises these services, which may include physical therapy, occupational therapy, or speech pathology services.
Condyle
The joint of the jaw is the condyle.
Continuation
State or federal (COBRA) option for a member who no longer qualifies as an active employee but can extend his or her insurance coverage for a specific amount of time. The member is responsible for any premium. This generally applies to medical coverage only, but can include dental depending on legislation and group size. Coverage and premium are the same as the group's.
Contract fee schedule plan
In this plan, participating providers agree to accept set fees for treatment.
Contract provider
This refers to a provider who agrees to abide by special terms, conditions, and reimbursement arrangements.
Contract types
Types of contracts or plans include Traditional, PPO, or Prepaid/DHMO selected.
Contract types (dental)
Type of contract or plan such as Traditional, PPO, or Prepaid/DHMO selected.
Contract year
This is the period of time from the effective date of the contract to the expiration date of the contract.
Contributory
An employer benefit plan in which employees pay at least part of the premium.
Conversion privilege
This certificate privilege allows the insured to choose to convert from a group life policy to an individual policy before leaving the group to continue insurance coverage.
Coordination of benefits
Provision in a contract that applies when a person is covered by more than one medical or dental plan. It requires that all programs coordinate payment of benefits to eliminate overinsurance or duplication of benefits.
Coordination of Benefits
If you have multiple benefits plans, the COB determines which plan pays benefits first.
Coordination of benefits (Dental)
Provision in a contract that applies when a person is covered by more than one group dental program, the coordination of benefits requires that all programs coordinate payment of benefits to eliminate overinsurance or duplication of benefits.
Coordination of benefits (Medicare)
If you have more than one health plan or insurance policy that covers the same benefits the coordination of benefits process will be used to determine which plan should pay first. If one of the plans is a Medicare health plan, federal law may decide who pays first. This is also called cross-over.
Copay
Copays are cost-sharing arrangements in which you pay a specified charge at the time for service for example, $15 for an office visit.
Copayment
This is the set amount you pay at the time you receive service from a provider. For example, you may have a $20 copayment for a family practitioner office visit, a $30 copayment for a specialist, and maybe even a $100 copayment for hospital admissions. Typically, if a service requires that you pay both a copayment and deductible, the copayment is paid first, then deductible, and then coinsurance.
Corporate services provider
A class of TRICARE-authorized providers consisting of institutional-based or freestanding corporations and foundations that render professional ambulatory or in-home care and technical diagnostic procedures.
Cost sharing
Cost sharing is the amount you pay for medical care or prescription drugs yourself. This may include a copayment, coinsurance, or deductible.
Coverage
Coverage refers to the benefits offered as part of your dental plan.
Coverage gap
There is a coverage gap for Medicare Part D in which you will be responsible for 100% of drug costs as your expenses for prescriptions exceed ordinary coverage but don’t yet meet the out-of-pocket threshold. To protect yourself, you should have what is called Donut Hole Coverage.
Covered benefit
A covered benefit is a health service or item your health plan pays for either partially or in full.
Covered entity
Under HIPAA, this is a health plan, a healthcare clearinghouse, or a healthcare provider who transmits any health information in electronic form in connection with a HIPAA transaction.
Covered expenses
These are qualifying costs that you incur and which your plan may pay or reimburse you for in accordance with the terms of your policy.
Covered person
This refers to an individual who meets a health plan's eligibility requirements and has paid the required premiums for coverage.
Covered services
These are qualifying services performed by your provider and which your plan may pay for or reimburse you for in accordance with the terms of your policy.
Covered services (Medicare)
Services a health plan pays for in part or in full, a covered service is defined and limited by statute. For instance, covered services under Medicare Supplement plans include most doctor services, care in outpatient departments of hospitals, diagnostic tests, durable medical equipment, ambulance services, and other health services that are not covered by Medicare Part A.
Credentialing
This is the process of approving a provider to participate in a benefit plan.
Credentialing (TRICARE)
The process by which providers are allowed to participate in the TRICARE network. This includes a review of the provider’s training, educational degrees, licensure, practice history, etc.
Creditable coverage (Medicare supplement plans)
This is any sort of health insurance plan that you are eligible to use which can shorten the pre-existing condition/ long waiting period that is part of your Medicare Supplement policy.
Creditable coverage (prescription drug plans)
This refers to prescription drug coverage (such as plans offered by an employer or union) that pays out, on average, as much as or more than Medicare’s standard prescription drug coverage.
Crown
This is the part of the tooth that rises above the gum line. The term crown may also be used to refer to a cap that your dentist places over your tooth.
Current amount
On the spending account Expenses Requiring Verification Table, this is the amount remaining that needs to be validated or repaid.
Cuspid
Pointed tooth used to tear food two upper and two lower. Also known as canines or eyeteeth.

D

D.D.S., D.M.D.
These abbreviations refer to academic degrees awarded to graduates of United States dental schools.
Date of service
This is the date when service was provided.
Date posted
For spending accounts, this is the date the transaction was completed and applied to your account.
Date processed
The date Humana processed a claim. Providers can expect to receive payment in 7-14 days, depending on the provider payment arrangement.
Days supply
The amount of days the prescribed medication is to last is the days supply. For example, you might receive a 30-day supply or 90-day supply.
Deadline to verify
On the spending account Expenses Requiring Verification Table, this is last date you are able to verify an expense was eligible for spending account reimbursement.
Death benefit
The amount payable after the death of the person whose life is insured.
Debridement
Debridement refers to the removal of foreign matter or dead tissue.
Decay
Decay is the decomposition of tooth structure.
Decay (dental)
Decomposed tooth structure (cavity formation).
Decline reason
On the spending account Declined Card Transactions Table, this is why Humana denied payment for a certain amount or transaction.
Deductible
This is a set amount you pay before your insurance starts to pay for specified services. For example, you may only have a copayment for physician services, but you may have to meet a deductible for hospital services.
Deductible carry-over credit
These charges, applied to the deductible for services during the last months of a calendar year, may be used towards the next year's deductible.
Defense Enrollment Eligibility Reporting System (DEERS)
A database of uniformed service members (sponsors), family members, and others worldwide who are entitled under law to military benefits, including TRICARE. Beneficiaries are required to keep DEERS updated. Refer to the TRICARE Eligibility section of your handbook for more information.
Defined standard coverage
This is the lowest or most basic level of prescription drug coverage that can be offered through Medicare Part D.
Dental coverage
Your dental coverage is the benefit that you pay premiums for. Your coverage will pay certain approved costs associated with preventing and treating dental disease.
Dental Health Maintenance Organization (DHMO)
DHMOs accept responsibility and financial risk for providing you with specified dental services during a set period of time at a fixed price. As a member, you receive comprehensive care through designated providers.
Dental prosthesis
This artificial device replaces one or more missing teeth.
Dentin
Dentin is tissue that forms the main body of the tooth.
Denture
A denture is an artificial substitute for natural teeth and adjacent tissues.
Denture base
This is the part of the denture that holds artificial teeth and fits over the gums.
Dentures
Any dental appliance to replace missing natural teeth and the surrounding tissues.
Dependent
For spending accounts, a dependent is a child under 13 years of age or someone who is disabled and receiving care through a day care service, nanny, etc., while a parent or guardian is at work, looking for work, or attending school. For other types of benefits, refer to the definition in your plan documents.
Dependent care FSA
See “Flexible Spending Account - dependent care.”
Dependent coverage
Insurance coverage that extends to your dependents, including spouse and dependent children, is known as dependent coverage.
Deposits to date
For spending accounts, this is the total amount contributed to your spending account as of a certain date.
Description
On the spending account Account Activity Tables, this is an explanation of the type of transaction or the type of provider. On the Claim Form, it is the type of service or procedure performed.
Designated Provider (DP)
Under the US Family Health Plan (USFHP), DPs, formerly known as uniformed services treatment facilities, are selected civilian medical facilities around the United States assigned to provide care to eligible and enrolled USFHP beneficiaries — including those who are age 65 and older — who live within the DP area. At these DPs, the USFHP provides TRICARE Prime benefits and cost-shares for eligible persons who enroll in USFHP, including those who are Medicare-eligible.
DHMO
See Dental Health Maintenance Organization.
Diagnostic services
Used to identify the cause of patients’ symptoms or the status of their pre-existing condition, diagnostic services may included a physical examination, radiology tests, blood tests, a study, or an invasive procedure. Most diagnostic services take place in an outpatient setting, although some may require a hospital admission or overnight stay in a hospital or diagnostic facility.
Diastema
Space between two adjacent teeth in the same jaw.
Digital X-ray
X-rays that are captured in digital format instead of on X-ray film, these can be seen immediately on a computer screen after exposure.
Disability benefit
This benefit is payable under a disability income policy.
Disabled enrollee
An individual under age 65 who has been entitled to disability benefits for at least two years may receive Medicare Part B benefits as a disabled enrollee.
Disclosure
This refers to the release of information by an entity to others not affiliated with that entity.
Disease management
A prospective, disease-specific approach to improving health care outcomes by providing education to beneficiaries through non-physician practitioners who specialize in targeted diseases.
Disenroll
You disenroll when you end your coverage with a health plan.
Distal
The surface of a tooth farthest from the center line of the face is known as distal
DOB
This stands for date of birth.
Document number
A number assigned by our computer system to each document received.
Dose
A dose is the amount of medication you are prescribed or instructed to take at one time as treatment for a specific condition.
DOT
The Department of Transportation (in this case, the United States DOT) is the federal agency governing interstate transportation.
Drug discount program
A discount drug program offers members of that program special savings on medications not covered by their pharmacy benefit plan.
Drug list
A list of medications your plan covers is the drug list, also known as a formulary. Humana’s Medicare Drug List shows which drugs are covered and which drug tier they’re in — preferred generic, preferred brand, non-preferred brand, or specialty. See the definition for drug tiers.
Drug tiers
Some plans place prescription drugs together in a group, or drug tier. With most plans, the amount you pay at the pharmacy depends on the tier for the drug.
Dual eligibles
People who are entitled to Medicare and eligible for Medicaid are dual eligible.
Durable Medical Equipment (DME)
DMEs refer to certain purchased or rented items that are prescribed by a healthcare provider for use in a patient’s home. Examples of durable medical equipment Medicare might cover include hospital beds, iron lungs, oxygen equipment, seat lift equipment, and wheelchairs.
Dynamic early intervention
Early intervention — The sooner treatment begins, the quicker the recovery. Early intervention also allows complicated cases to be identified quickly, so that appropriate referrals can be made immediately - Early motivation — A good first experience with our physicians and staff motivates patients and creates a positive attitude that shortens rehabilitation time- Early education — We help patients understand the mechanics of the injury and methods to prevent re-injury , so they feel more in control of their recovery - Self-responsibility — We clearly communicate and emphasize the patient’s responsibility in the treatment and recovery process, which leads to more successful outcomes

E

Effective date
This is the date on which your coverage begins.
Effective date (HumanaOne)
People who are entitled to Medicare and eligible for Medicaid are dual eligible.
Election
An enrollment in or voluntary disenrollment from a Medicare Advantage plan, Medicare prescription drug plan, or Medicare Parts A and B is called an election.
Election period
Your election period is the time during which you can join a Medicare plan through a private insurer or Medicare Parts A and B.
Electronic Data Interchange (EDI)
A method of enrollment where the enrollment information for the retiree is provided by the group benefits administrator to Humana in an electronic file, the EDI includes necessary information such as your HCFA number, geographic data and date of birth
Eligibility
Requirements that must be satisfied by people who wish to be insured to establish eligibility.
Eligibility date
This is the date on which you become eligible to apply for benefits under the benefit plan.
Eligibility period
The eligibility period is a specified length of time, following the eligibility date, during which you remain eligible to apply for benefits under a benefit plan without evidence of insurability.
Eligibility: Medicaid
This refers to the process in which the state decides whether or not you are qualified for healthcare coverage through the Medicaid program.
Eligibility: Medicare Part B
You are automatically eligible for Part B if you are eligible for premium-free Part A. You are also eligible for Part B if you are not eligible for premium-free Part A but are age 65 or older AND a resident of the United States or a citizen or an alien lawfully admitted for permanent residence. In this case, you must have lived in the United States continuously during the five years immediately prior to the month during which you enroll in Part B.
Eligibility: Medicare Part D
To enroll in Medicare Part D (the prescription drug plan), you must be eligible for Medicare Part A and/or enrolled in Part B; you must also live in the geographic area where the plan you want to enroll in is offered.
Eligible dependent
This is a dependent, such as a spouse or a child, who qualifies to receive coverage under your insurance plan. As the policy holder, you may need to pay an additional premium to cover an eligible dependent.
In most states, you can enroll children who are between 2 weeks old and 25 years old in a HumanaOne health benefits plan. Qualifications for eligible dependents may vary for Short-Term Medical plans.
Eligible expenses
This is either the maximum allowable charge or a set service fee for dental or vision services and supplies — whichever is lower — that your plan will cover.
Eligible Person
This includes former employees (or their eligible dependents) of a group and its participating affiliates who are eligible to participate in a Medicare Advantage plan.
Emergency care
Emergency care is given for a medical situation in which you believe your health is in serious danger.
Emergency room (hospital)
The area of a hospital solely designated for diagnosing and treating emergency injuries or illnesses is the emergency room.
Employer authorization form
An employer must complete this mandatory Concentra form, and the employee must bring it to a Concentra medical center in order to be admitted as a patient.
Enamel
The hard surface covering the dentin portion of the crown of the tooth is enamel.
End date
Date on which the member's coverage ends.
End Stage Renal Disease (ESRD)
Permanent kidney failure requiring dialysis or a kidney transplant is known as WSRD.
Endodontics (root canals)
Root canals are a dental specialty concerned with the treatment of diseases of the dental pulp (nerves, blood vessels, etc., within the tooth).
Endodontist
Endodontists are dental specialists who limit their practice to treating disease and injuries of tooth pulp.
End-Stage Renal Disease (ESRD)
ESRD is permanent kidney failure that requires dialysis or a kidney transplant.
Enrolled member
An eligible person who has elected to enroll in a Humana Group Medicare plan is an enrolled member.
Enrollee
This refers to an individual covered by a benefit plan.
Enrollment booklet
This booklet or pamphlet contains a general explanation of your plan's benefits. It is also known as Summary Plan Descriptions.
Enrollment period
This refers to the range of days during which you can join a Medicare health plan if it is open and accepting new Medicare members. If a health plan chooses to be open for enrollment, it must allow any eligible person with Medicare to join.
EOB
An EOB is the Explanation of Benefits that explains how your plan will pay your claim.
Ergonomics
This is the study of how individuals interact with their environment. In a work setting, ergonomics can be used to design tasks, tools, or equipment to improve productivity and/or prevent injury.
Erosion
Defect in the surface of a tooth, which cannot be accounted for by abrasion, in which the enamel is worn and smooth. This usually results from chemical action in the mouth.
Erupt, eruption
When a new tooth comes in, it erupts when it breaks the surface of the gums, and you can see it.
Erupt/eruption
In dental care, this refers to when a new tooth comes in. It erupts when it breaks the surface of the gums and you can see it.
Estimate
Details on how benefits would be covered by a member's plan when a provider submits an estimate of services.
Estimated retail price
This is the average cost of a drug on the open market. This price is calculated from a national average wholesale price and does not take into account a prescription drug benefit, the actual cost of a specific drug, mail-order savings, or possible reimbursements to the dispensing pharmacy. Pricing may vary by pharmacy and by the specific quantity, strength, and dosage of the medication. You should always contact your pharmacy for details on pricing for specific medications.
Evidence of coverage
This is a complete list of your benefits under a Medicare Advantage plan.
Evidence of Coverage (EOC)
A CMS approved document that details plan benefits and services, the EOC includes CMS mandated amendments that may occur during the year. All Humana Group Medicare enrolled members, will receive a copy of the EOC as well as any amendments that are mandated during the plan year.
Evidence of insurability
Medical information that shows an individual is medically eligible for insurance coverage is known as evidence of insurability. You may or may not need to provide this information, depending on your employer's contract with Humana.
Evidence-based medicine
Medical best practices that are based on the actual, observed results of patient treatment as opposed to theory or generalized medical practice is known as evidence-based medicine
Excluded amount
The amount that was excluded from payment consideration. For example, if the doctor has a discounted arrangement with Humana, that amount will show up in this space with an explanation below. In such a situation, you are not responsible for this amount.
Exclusions
Services not covered under your benefit plan are referred to as exclusions.
Exclusive Provider Organization (EPO)
If you belong to an EPO, you must receive care from affiliated providers; services rendered by unaffiliated providers are not reimbursed.
Expenses requiring verification
For spending accounts, these are expenses that Humana's systems have not verified. You may need to submit receipts or copies of Explanation of Benefits (EOBs) for these expenses to meet IRS and plan requirements.
Expiration date
This is the date on which your dental contract expires. It may also refer to the date on which you are no longer eligible for benefits.
Explanation of benefits (EOB)
The EOB is not a bill. It details how the claim was processed and indicates the portion of the claim paid to the provider and the portion of the claim you need to pay (if applicable).
Explanation of Benefits (EOB)
The EOB is not a bill. It details how the claim was processed and indicates the portion of the claim paid to the dentist and the portion of the claim you need to pay (if applicable).
Extended Care Health Option (ECHO)
ECHO is a supplemental program to the TRICARE basic program. It provides eligible and enrolled ADFMs with additional benefits for an integrated set of services and supplies designed to assist in the treatment and/or reduction of the disabling effects of the beneficiary’s qualifying condition. Qualifying conditions may include moderate or severe mental retardation, a serious physical disability, or an extraordinary physical or psychological condition such that the beneficiary is homebound.
Extraction
Separation and surgical removal of a tooth from its surrounding tissues.
Eyeteeth
Pointed teeth used to tear food (two upper and two lower), also known as cuspids or canines.

F

Family deductible
Deductible that may be satisfied by the combined expenses of all covered family members.
Federal employee health benefits
This refers to benefits programs for federal employees, retirees, and their survivors. Contact the U.S. Office of Personnel Management if you have questions about your Federal Employee Health Benefits.
Fee for service
This refers to traditional provider reimbursement in which providers are paid according to their fee for a specific service.
Fee schedule
This is a list of the charges for specific services that a provider agrees to.
Filling
Material used to fill a cavity in a tooth. The substance may be gold, silver amalgam, copper amalgam, acrylic resins, porcelain, or cement.
Final claims deadline
For spending accounts, this is the last date a claim can be filed and still be reimbursed out of your spending account.
Fixed appliances
These are appliances that are cemented or bonded to teeth.
Fixed partial denture
An artificial device that replaces one or more missing teeth, a fixed partial denture is cemented or otherwise attached to abutment teeth or implant replacements.
Flexible Spending Account
An employer-sponsored spending account that allows subscribers to contribute, on a pre-tax basis through paycheck deduction, to a Healthcare FSA or Dependent Care FSA. As you incur eligible expenses, outlined by the IRS, you may request reimbursement from the FSA. Any reimbursements you receive from these accounts remain tax-free when they are paid to you.
Flexible Spending Account - dependent care
An employer-sponsored spending account that allows subscribers to contribute funds on a pre-tax basis through paycheck deduction. Employees can use a Dependent Care FSA to pay for IRS-approved dependent care services, such as child day care, adoption-related costs, and adult care.
Flexible Spending Account – healthcare
An employer-sponsored spending account that allows subscribers to contribute funds on a pre-tax basis through paycheck deduction. Employees can use a Healthcare FSA to pay for qualified medical expenses not covered under the health plan.
Fluoride
Fluoride is a chemical solution or gel hat you place on your teeth to help prevent decay.
Foreign Identification Number (FIN)
A permanent identification number assigned to a North Atlantic Treaty Organization (NATO) beneficiary by the appropriate national embassy. The number resembles a Social Security Number and most often starts with 6 or 9. TRICARE will not issue an authorization for treatment or services to NATO beneficiaries without a valid FIN.
Form
Medication may be administered in a variety of forms that include as a tablet or oral liquid.
Formulary
The formulary is a list of medications your plan covers (also known as a drug list). Humana's Medicare Drug List shows which drugs are covered and which drug tier they are in — Preferred Generic, Preferred Brand, Non-Preferred Brand, or Specialty. See the definition for drug tier.
Freestanding radiology facility
Usually housed within a building separate from a hospital or operating independently of a hospital, freestanding radiology facilities provide imaging studies that are used to help detect or diagnose a medical condition. Tests administered at these healthcare facilities may include scans such as MRI, CAT, and PET, as well as ultrasound and X-ray studies. Test results are interpreted by board-certified radiologists and reported to the referring physician.
Frenectomy
Surgical cutting of the frenum, a piece of pink-colored skin that attaches your lips, cheeks, and tongue to your mouth.
Frenum
The piece of pink-colored skin that attaches your lips, cheeks, and tongue to your mouth is the frenum.
FSA
See “Flexible Spending Account.”
FSA grace period
Time when you can still incur expenses and pay for them with any remaining dollars from your previous plan year. This feature is not available to all; check with your employer.
Full-mouth X-rays
An entire set of X-rays, usually consisting of 14-22 films, full mouth X-rays display the anatomical crowns and roots of all the teeth and the bone around them.

G

General anesthesia
General anesthesia produces a controlled state of unconsciousness, accompanied by a partial or complete loss of reflexes.
General anesthetic
This drug causes loss of feeling, generally, or renders the patient unconscious.
Generic prescription drugs
Generic drugs use the chemical name of the drug and are less expensive than brand-name drugs. They're chemically identical to their name-brand counterparts and meet Food and Drug Administration (FDA) standards for safety, purity, and effectiveness.
Gingiva
Gum tissue surrounding the teeth and covering the bone of the upper and lower jaws.
Gingivectomy
This refers to the cutting away of loose, infected, and diseased gum tissue.
Gingivitis
Inflammation of the gums without loss of connective tissue is called gingivitis.
Gingivoplasty
This surgical procedure reshapes the gums.
Grace period
A specified period following the date a premium payment is due is called a grace period.
Grievance
A grievance is a complaint about the manner of service provided by a healthcare provider. For example, you may file a grievance when a facility you visited was not clean, staff at a facility behaved unprofessionally, or there was a problem related the operating hours. A complaint about a treatment or coverage decision should be filed as an appeal. See the definition for appeal.
Grievance procedure
Through this procedure, a member of a plan or a provider of benefits may express complaints and receive a response.
Group
Used interchangeably with employer, group benefits administrator, and contract holder.
Group certificate
This document shows the benefits provided under the group contract.
Group ID
Number assigned to each case or group when we receive the application. It identifies the group in our computer system and remains with the account permanently.
Guaranteed insurability
This is an option that enables you to buy additional life insurance without being required to provide evidence of insurability.
Guaranteed issue amount
This provision allows a certain amount of insurance to be issued without evidence of insurability.

H

Hard palate
This refers to the area of the palate (approximately two-thirds of the front section), composed of relatively hard and unyielding tissue.
Health Maintenance Organization - HMO (Medicare)
HMOs are a type of Medicare Advantage Plan available in select areas of the country. Plans must cover all Medicare Part A and Part B healthcare. Some HMOs cover extra benefits, like extra days in the hospital. In most HMOs, you can only go to doctors, specialists, or hospitals on the plan’s list except in an emergency. Your costs may be lower than in Medicare Parts A and B only. Get more information on Humana Gold Plus HMO plans.
Health Maintenance Organization (HMO)
With an HMO, you select a primary care physician (PCP) who's in the plan's network. Your PCP tends to most of your health needs and refers you to a specialist in the network when necessary.
Health plan

A health plan provides insurance protection against illnesses or injury. In addition, some health plans cover the costs of preventive care such as routine checkups.

HumanaOne offers a wide range of health plans for individuals and their families. Benefits of these plans may include coverage for inpatient and outpatient hospital services, preventive care treatment by specialists, and prescription drugs.

Health Savings Account (HSA)
An HSA is a tax-deductible savings account that you contribute to and can then draw on to pay for qualifying medical expenses. You must be enrolled in an IRS-qualified High Deductible Health Plan to set up a Health Savings Account.HumanaOne offers several High-Deductible Health Plans that can be combined with a Health Savings Account to save money, tax-free, for medical expenses.
Healthcare FSA
See “Flexible Spending Account – healthcare”
Healthcare provider
This is a provider of services, such as a dentist.
Hemisection
Surgical division of a tooth to allow salvage of one part of the tooth that is relatively free of disease.
High-Deductible Health Plan
This specially designed plan has one deductible that combines medical and prescription drug expenses. An HDHP is usually a Preferred Provider Organization (PPO) plan, but it also could be an HMO or Point of Service (POS) plan.
HIPAA
The "Health Insurance Portability and Accountability Act of 1996." HIPAA includes four key components: Electronic Transactions, Portability, Privacy, and Security.
HMO
HMO is short for a Health Maintenance Organization. It's a type of plan that allows you to choose a primary care physician (PCP) in the plan's provider network to coordinate your care.
HMO plan
See the definition for Health Maintenance Organization (HMO).
Home healthcare
This refers to skilled nursing care and certain other healthcare you get in your home for the treatment of an illness or injury.
Hospice
A special way of caring for people who are terminally ill, hospice care includes physical care for the patient as well as counseling for the patient and the patient’s family. Hospice care is covered under Medicare Part A.
Hospital
A hospital is an institution that provides inpatient, outpatient, emergency, diagnostic, and therapeutic services while participating in and being eligible for payments under the Medicare program. The term “hospital” does not include a convalescent nursing home, rest facility, or other facility for the aged that provides assistance with daily living (referred to as “custodial care”).
HSA
See “Health Savings Account (HSA)”
HSA Transaction Block
This feature prevents all reimbursements from your Health Savings Account (HSA). When you enable the transaction block, you enjoy the benefits that come with saving HSA funds - tax-free growth, investment opportunities, and preparation for future expenses. This feature is not available to all.
Human performance evaluation
A functional test developed after the measurement of a given position’s essential job functions; this test helps the employer assess the applicant’s/employee’s ability to perform the job and/or to return to work following an injury.
Human-life value
A method to determine life insurance needs, it is based on income, expenses, potential earnings, and the projected depreciation of the dollar.
Hygienist
A trained, licensed person who performs dental prophylaxis under the direction of a licensed dentist is a hygienist.

I

Identification card
This is a card given to each person covered under a benefit plan.
Immediate denture
This denture is constructed for insertion immediately after removal of natural teeth.
Immunoassay
This is a test using antibodies to identify and quantify substances; often the antibody is linked to a marker such as a fluorescent molecule, a radioactive molecule, or an enzyme.
Impacted tooth
Tooth that has not erupted and is embedded in the jaw.
Implant
An implant is an artificial device specially designed to be placed surgically within or on the jawbones to replace teeth.
Implant (dental)
Device of metal or other foreign material that is surgically placed into or on the upper or lower bone to support a crown, bridge, or partial or full denture.
Implantation
Implantation is the process of placing an artificial or natural tooth into bone.
Impression
This is a mold of one or more teeth.
In area
In-area refers to healthcare providers and services that are available to members within the geographic area that a specific health plan services.
In network
These are providers who have contracts with a benefit plan to provide services at a set rate.
In process
Indicates an estimate or a claim has been received but processing is not complete.
Incisal
Incisal is the cutting edge of the front teeth.
Incisor
A cutting tooth in the front of the mouth four on the upper jaw and four on the lower jaw.
Incomplete application
This refers to an application in which one or more of the required elements established by CMS are not complete. For example: the form isn't signed by the beneficiary or the legal representative, supporting documentation for a representative's signature isn't included, necessary elements on the form are not completed, or entitlement to Part A cannot be established.
Incurred claims
Incurred claims equal the claims paid during the policy year plus claim reserves.
Indemnity insurance
This traditional fee-for-service coverage allows providers to be paid according to their service fees.
Individual allowance
The amount Humana pays toward the cost of a covered prescription drug is known as individual allowance.
Individual deductible
Amount of eligible expenses a covered person must pay each year before the benefit plan will pay for eligible benefits.
In-force business
Coverage for which premiums are being paid or for which premiums have been fully paid is referred to as in-force business.
Initial Coverage Election Period
ICEP is the three-month span immediately before you are entitled to Medicare Part A and enrolled in Part B. During this time you can choose a Medicare health plan.
Initial Enrollment Period (IEP)
The first chance you have to enroll in Part B is during your IEP, a seven-month period that begins three months before the month you are first eligible for Medicare Part B. Usually, this means the IEP begins three months before the month in which you turn 65 years old. It ends three months after you turn 65. The Initial Enrollment Period is different from the Initial Coverage Election Period. See definitions for Eligibility: Medicare Part A and Initial Coverage Election Period.
Injury
Injury is bodily harm that results directly from an accident, independent of disease or bodily infirmity or any other cause.
Inlay
A porcelain or metal restoration to be inserted into a previously prepared cavity in a tooth and retained with cement.
In-network coverage
In-network coverage refers to the eligible benefits that are offered when you choose an in-network or participating provider.
In-network providers
A healthcare provider (such as a doctor, hospital, other medical facility, or pharmacy) is considered an in-network provider if it has agreed to charge a set rate for members of a health benefits plan. Your network choices may vary, depending on your plan and where you live. With PPO and HMO plans, you can reduce your costs by using in-network providers, which are also known as participating providers.
Inpatient
You are considered an inpatient if you have been registered and admitted to a healthcare facility and have been charged for room and board.
Inpatient care
Healthcare you receive while admitted to a hospital is inpatient care.
Inpatient hospital
An inpatient hospital admits patients and primarily provides the following services by or under the supervision of physicians: diagnostic services, surgical and non-surgical therapeutic services, and rehabilitation services. Psychiatric facilities, even if they admit patients, are not considered inpatient hospitals.
Inpatient hospital services
These services include bed and board, nursing services, diagnostic or therapeutic services, and medical or surgical services.
Insured
This refers to someone covered by an insurance benefits plan.
Insurer
An insurer is an organization that bears the financial risk for services and material provided to an individual or group.
Interproximal surface
Surface of a tooth that faces its adjoining tooth as they stand in the line in the dental arch.
Intravenous sedation/analgesia
This is a medically controlled state of unconsciousness that involves maintaining a patient's airway, reflexes, and the ability to respond to stimulation or verbal commands. It requires use of a sedative and/or pain reducing IV and monitoring.

J

Jacket
A full dental crown constructed of porcelain or plastic.
Jaw
The term to indicate either the maxilla (upper) or mandible (lower).

L

Labial surface
In dental care this term refers to the surface of the front teeth that faces the lip.
Laceration
This refers to a torn and ragged wound.
Lapse
A policy lapses and is terminated if the insured fails to pay the premium.
Last paid
For a spending account, this is the date when funds were most recently taken out of your account to pay expenses.
Late applicant
Member and/or member's eligible dependent who enrolls or is enrolled for coverage more than 31 days after his or her eligibility date. Late applicants may be subject to a waiting period.
Liability
This refers to an obligation an individual or organization has for a specified amount or action.
Lifetime maximum
This is the maximum amount your plan will pay toward eligible expenses while you're covered under the plan.
Lifetime maximum benefit
This is the total amount a health plan will pay, per covered member, for the lifetime of the coverage.
Lifetime orthodontic services
The maximum amount payable (for each covered person) for eligible charges related to treatment, no further benefits are payable after this maximum is reached.
Limitation and exclusions
Conditions listed in a policy for which benefits are not paid are limitations and exclusions.
Limitations
Limitations are items or services a health plan does not cover.
Limiting charge
The highest amount of money you can be charged for a covered service by doctors and other healthcare suppliers who do not accept Medicare assignment, the limiting charge only applies to certain medical services, not to medical supplies or equipment.
Line status
The status of each line item in the claim can be paid, denied, or in process. Each line item may have a different status; however, if the entire claim is pending for review, each line item will indicate “in process.”
Lingual surface
Surface of the tooth toward the tongue.
Local anesthesia
This type of anesthesia, such as Novocaine, eliminates sensation, especially pain, in a part of the body by topical application or injection of a drug.
Locked-In period
If you have a Medicare Advantage and prescription drug plan, you are "locked-in," which means (unless you qualify for special circumstances) you can only switch plans during certain times of the year. The lock-in period runs from April 1 to November 14.
Long-term care hospital
A hospital that has an average inpatient length of stay of greater than 25 days is a long-term care hospital.
Lump sum
These proceeds are paid to beneficiaries all at once instead of in installments.

M

Major services
For dental plans, these are procedures concerned with the restoration of teeth by cast restorations such as inlays, onlays, crowns, or veneers. Major services may include endodontics (root canals) or periodontics (tissue/bone treatment).
Malocclusion
Abnormal position of the teeth or jaws.
Managed care
This is a healthcare system under which providers are organized into a network in order to manage the cost, quality, and access to healthcare. Managed care organizations include Preferred Provider Organizations (PPOs) and Dental Health Maintenance Organizations (DHMOs).
Managed Care Support Contractor (MCSC)
An MCSC is a civilian health care contractor of the Military Health System that administers TRICARE in one of the TRICARE regions. An MCSC (Humana Military is an MCSC) helps combine the service available at MTFs with those offered by the TRICARE network of civilian hospitals and providers to meet the health care needs of the TRICARE beneficiaries.
Managed-care organization
Managed care organizations serve Medicare or Medicaid beneficiaries with a network of employed or affiliated providers. These organizations usually include Health Maintenance Organizations, Preferred Provider Organizations, and Private Fee-for-Service plans.
Mandible
This is the horseshoe-shaped bone that forms the lower jaw.
MAPD
A Medicare Advantage plan (HMO, PPO, or PFFS) combined with a Prescription Drug Plan (PDP) for one total monthly premium, MAPD is administered by a Medicare Advantage Organization (MAO).
Max
Short for maximum.
Maxilla
This refers to bones that form the upper jaw.
Maximum allowance
The maximum dollar amount a benefits program will pay towards the cost of a service is the maximum allowance. This is specified in the program's contract provisions, (e.g. Usual, Customary, and Reasonable [UCR] Table of Allowances).
Maximum annual benefit (MAB)
This is the maximum dollar amount a health plan will pay during a plan period. The plan period is usually your effective date through the end of the calendar year.
Maximum benefit
This is the maximum dollar amount a benefit program will pay toward the cost of care for an individual or family within a specific period.
Maximum fee schedule
This refers to an arrangement in which a participating provider agrees to accept a set amount as the total fee for one or more covered services.
Maximum medical out-of-pocket
This is the most money you will be required to pay within a year for deductibles and coinsurance. Regular premiums are not included in calculations of your maximum medical out-of-pocket expenses.
Maximum plan benefit coverage
The maximum dollar amount a health plan will pay during a benefit period is called the maximum plan benefit coverage. Medicare plans usually only set this type of limit on services for which the plan offers enhanced benefits.
Mbr Resp Amt
This abbreviation means member responsible amount.
Medicaid
A joint federal and state program, Medicaid helps cover medical expenses for low-income individuals. Medicaid programs vary from state to state, but most healthcare costs are covered if you qualify for both Medicare and Medicaid.
Medical insurance (Medicare Part B)
Medical expenses such as doctors' services, outpatient hospital services, and a number of other non-hospital medical services and supplies are covered under Medicare Part B.
Medically necessary
Healthcare services or supplies that are deemed appropriate for a particular sickness or injury are referred to as medically necessary. Just because a provider prescribes, authorizes, or performs a service does not mean it will be considered medically necessary under your insurance plan or that the costs will be covered. To be considered medically necessary, a service or supply must meet the standards of good medical practice and be the most appropriate care that can be safely provided to you. Medically necessary services do not include those offered solely for your convenience or the convenience of a doctor or hospital.
Medicare
Medicare is the federal health insurance program available to people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD).
Medicare + Choice
Now called Medicare Advantage.
Medicare Advantage Health Maintenance Organization (HMO) plan
See the definition for Health Maintenance Organization (HMO).
Medicare Advantage Organization
This is a state-licensed public or private entity that meets Centers for Medicare & Medicaid Services (CMS) requirements to hold a Medicare Advantage contract.
Medicare Advantage Organization (MAO)
The state licensed business entity, certified by CMS as meeting the Medicare Advantage requirements, MAO offers a plan or plans and is legally responsible for any liability associated with the delivery or non-delivery of services offered through the plans.
Medicare Advantage Plan (MA)
A Medicare plan offered by a private insurer, an MA includes all of the benefits of Original Medicare (also called traditional Medicare) and may also include Medicare Part D prescription drug coverage, as well as extra benefits. When you have a Medicare Advantage plan, you still have Medicare and must continue paying Medicare premiums.
Medicare Advantage Preferred Provider Organization (PPO) plan
See the definition for Preferred Provider Organization (PPO).
Medicare Advantage Private-Fee-for-Service (PFFS) plan
See the definition for Private Fee-for-Service (PFFS).
Medicare and You Handbook
This booklet includes information on things such as how to file a claim and what type of care is covered under the Medicare program. All Medicare beneficiaries receive this handbook when they first enroll in the program.
Medicare benefits
Health insurance available under Medicare Part A and Part B is also known as your Medicare benefits.
Medicare coverage
Medicare coverage consists of two parts: Hospital Insurance (Part A) and Medical Insurance (Part B). See the definitions for Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance)
Medicare Part A (hospital insurance)
This federal insurance covers hospital expenses such as room and board and other inpatient hospital services.
Medicare Part B (medical insurance)
Medical expenses such as doctors' services, outpatient hospital services, and a number of other non-hospital medical services and supplies are covered under this federal insurance program.
Medicare Part C (Medicare Advantage plans)
This coverage is offered by a Medicare Advantage Organization. You receive a specific set of health benefits at a uniform premium and uniform level of cost-sharing. Part C is available to all Medicare beneficiaries who live within a plan's service area.
Medicare Part D (prescription drug coverage)
This optional Medicare prescription drug coverage is offered through private companies and organizations. You can get Part D coverage through a Medicare-approved stand-alone drug plan or a Medicare Advantage HMO, PPO, or PFFS plans that includes drug coverage.
Medicare Parts A and B
This pay-per-visit health plan lets you go to any doctor, hospital, or other healthcare provider who accepts Medicare. Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance plus the deductible). See the definitions for coinsurance and deductible.
Medicare premiums
This is the monthly premium you pay for your Medicare Part A coverage, Medicare Part B coverage, or Medicare Part D coverage.
Medicare savings programs
Through these programs, millions of people with Medicare are able to save money each year. States have programs for people with limited incomes and resources that pay Medicare premiums. Some programs may also pay your Medicare deductibles and coinsurance.
Medicare select insurance plan
A type of Medicare Supplement policy, this plan may require you to use hospitals and, in some cases, doctors within its network to be eligible for full benefits. Contact your state insurance department for more information.
Medicare Supplement open enrollment period
This is a one-time-only, six-month period when federal law allows you to buy any Medicare Supplement policy that is sold in your state. It starts in the first month that you are age 65 or older and covered under Medicare Part B. During this period, you can't be denied a Medicare Supplement policy or charged more due to past or present health problems. Some states may have additional open enrollment rights under state law.
Medicare-approved amount
This is the amount Medicare and you pay to a doctor or supplier for a service or supply. It may be less than the actual amount charged by a doctor or supplier.
Medicare-required drugs and supplies
These are specific prescription drugs and products Medicare requires private insurers to cover.
Member
A member is an individual enrolled in a benefit program.
Member ID
Unique identifying number for a member who has a Humana plan. This number can be found on the member ID card Humana sends.
Member name
The name of the person for which a claim is submitted.
Mesial
Surface of the tooth toward the center of the mouth.
Military Treatment Facility (MTF)
An MTF is a medical facility (hospital, clinic, etc.) owned and operated by one of the component services of the Department of Defense (e.g., U.S. Army, U.S. Navy, and U.S. Air Force) and usually located on or near a military installation.
Molars
The last three teeth in the upper and lower left and right sides of the mouth in an adult, these 12 teeth are for grinding food. The baby set of teeth has eight molars.
Monthly premium
This is the monthly payment you make to an insurance company or a healthcare plan for healthcare coverage in addition to your Medicare Part A or Part B premium.
MRO
A Medical Review Officer is a physician qualified to interpret the results of drug testing.
My Drug List
You can create this online by selecting and adding to your list any drugs you take now or expect to take. You can then also use the Rx Calculator to estimate your prescription drug costs.
Myofacial pain dysfunction (MPD)
Hyperactivity of the jaw, usually affecting the facial muscles and chewing muscles.

N

National Provider Identifier (NPI)
The NPI is a 10-digit number used to identify providers in standard electronic transactions. It is a requirement of the Health Insurance Portability and Accountability Act of 1996.
Necessary treatment
A procedure or service that is essential for maintaining your health is designated as necessary treatment.
Network
A network is a group of healthcare providers who have agreed to charge a set rate for members of a health benefits plan. Providers on the list of network members are also called participating providers. Your network choices may vary, depending on your plan and where you live.
Network (and in-network provider)
Humana has negotiated lower rates from specific doctors, hospitals, and other providers, so these providers are part of Humana's networks and are referred to as in-network providers. They are also called participating providers.
Network deal
Financial agreement applied to a specific dentist or dental network.
Network/participating provider
Also known as in-network providers, these include hospitals, healthcare treatment facilities, healthcare practitioners, and other providers who enter into an agreement with an insurer and are, therefore, designated to provide services to anyone covered by that insurance provider.More than 350,000 doctors are members of Humana's network and provide discounts to Humana health plan members.
Non-Availability Statement (NAS)
A certification by a commander (or a designee) of a uniformed services MTF, recorded in DEERS, generally for the reason that the needed medical care being requested by a non-TRICARE Prime enrolled beneficiary cannot be provided at the facility concerned because the necessary resources are not available in the time frame needed.
Non-contributory
Employee benefit plans paid for by the employer, non contributory plans require that 100% of eligible employees participate.
Non-duplication of benefits
This stipulation in a contract relieves a third-party payer of liability for cost of services in cases where services are covered under another program. Non-duplication of Benefits is distinct from Coordination of Benefits because
Non-formulary drugs
Non-formulary drugs are those not included on a plan-approved list.
Non-intravenous conscious sedation
This medically controlled state of unconsciousness maintains a patient's airway, reflexes, and the ability to respond to stimulation or verbal commands. The sedative and/or analgesic agent(s) are provided by a method other than IV.
Non-network (Medicare Advantage plans)
This refers to doctors, hospitals, pharmacies, and other healthcare professionals or suppliers who do not belong to a health plan's provider network. See the definition of network.
Non-participating pharmacy (Medicare Advantage plans and Medicare prescription drug plans)
See definition for out-of-network pharmacy.
Non-participating physician (Medicare advantage plans)
See definition for out-of-network doctor.
Non-participating provider
Any provider who is not a part of the network of a benefit plan is considered a non-participating provider.
Nonprecious metals
Materials developed for all types of restorative procedures that are less costly than gold and other precious metals.
Non-precious metals
Materials developed for all types of restorative procedures, these are less costly than gold and other precious metals.
Non-preferred brand drug
Higher-cost brands that include drugs with preferred generic or therapeutic alternatives are referred to a non-preferred brand drugs. This may includes some self-administered injectable medications.
Non-preferred pharmacy
This is a network pharmacy that offers covered Part D drugs at negotiated prices but at higher cost-sharing levels than a preferred pharmacy.
Nonqualified amount
For a spending account, this is the amount that is not reimbursable from your account based on plan or IRS rules.
Nonqualified expense
For a spending account, this is an expense that is not reimbursable from your account based on plan or IRS rules.
Nursing facility
A nursing facility primarily provides skilled nursing care and related services to residents. Services may include rehabilitation for people who are injured, disabled, or sick. Nursing facilities may also provide regular health-related care services above the level of custodial care. These facilities do not usually include services for those with mental disabilities.
Nursing home
These homes provide residents with a room, meals, and help with activities related to daily living and recreation. Generally, nursing home residents have physical or mental problems that keep them from living on their own. They usually require daily assistance.

O

Occlusal
Biting or grinding surfaces of molars and bicuspids.
Occlusal guard (night guard)
Removable appliance, usually constructed of plastic, that covers one or both dental arches; designed to minimize the damaging effects of teeth grinding.
Occlusion
Contact between the biting or chewing surfaces of upper and lower teeth is called occlusion.
Occupational therapy
After an illness or injury, you many lose the ability to perform everyday activities such as bathing, preparing meals, or housekeeping. Occupational therapy helps you resume these life activities. It can be offered as inpatient or outpatient services.
Occusource
This refers to Concentra medical centers’ proprietary software for collection, maintenance, and analysis of patient information.
Office visit
A term that refers to services performed in a provider's office.
Onlay
Restoration that is extended to cover the entire incisal or occlusal surface of the tooth, an onlay is often used to restore lost tooth structure and increase the height of the tooth.
Open access
See Open Panel.
Oral surgeon
This type of dental is a specialist whose practice is limited to diagnosing and performing surgery or associated treatments for diseases, injuries, deformities, and defects of the oral region.
Oral surgery
This dental specialty is concerned with the surgical procedures in and about the mouth and jaw.
Original amount
For a spending account, this is the amount you requested for reimbursement from the account.
Orthodontic services
These services refer to a dental specialty concerned with the correction of improper alignment of the upper and lower teeth.
Orthodontist
A dental specialist, an orthodontist’s practice is limited to treating misaligned teeth and their surrounding structures.
OSHA
The Occupational Health and Safety Administration is a federal agency under the Department of Labor that publishes and enforces safety and health regulations for most businesses and industries in the United States.
Osseous
Pertaining to bone.
Other insurance paid amount
The amount paid by your other primary insurance.
Out-of-area
Out-of-area refers to services members of a Medicare Advantage receive from providers that have no contractual or other relationship with the plan.
Out-of-network
This refers to doctors, hospitals, pharmacies, and other healthcare professionals or suppliers who do not belong to a health or drug plan's provider/pharmacy network. See the definition of network.
Out-of-network benefit
Generally, an out-of-network benefit gives you the option to use a doctor, specialist, or hospital that is not a part of the plan's contracted network. In some cases, your out-of-pocket costs may be higher for an out-of-network benefit.
Out-of-network doctor
A primary care physician or specialist who does not belong to a health plan's provider network is considered an out-of-network doctor. In some cases, your out-of-pocket costs may be higher if you choose to use an out-of-network doctor. See the definition of network.
Out-of-network pharmacy
This is a pharmacy that is not under contract with Humana. By choosing an out-of-network pharmacy, you may pay more through coinsurance. These providers may also bill you for costs that are not covered by your insurance plan. In addition, you will need to meet an out-of-network deductible (separate from your in-network deductible) before Humana begins to pay for covered services.
Out-of-network provider
Also called non-participating provider, this term refers to providers who are not part of the Humana network and, therefore, will cost you more.
Out-of-pocket costs
These are healthcare costs that you pay on your own because they are not covered by your Medicare plan or other insurance.
Out-of-pocket maximum
This is the annual limit on your costs. After you meet the maximum out-of-pocket amount, your plan pays 100% for covered services. You may still pay copayments. Refer to the plan's Benefits Summary for more details.
Outpatient Prospective Payment System (OPPS)
TRICARE OPPS is used to pay claims for hospital outpatient services. TRICARE OPPS is based on nationally established Ambulatory Payment Classification payment amounts and standardized for geographic wage differences that include operating and capital-related costs, which are directly related and integral to performing a procedure or furnishing a service in a hospital outpatient department. TRICARE OPPS became effective May 1, 2009.
Outpatient services
This refers to a service you receive within one day — 24 hours — at a hospital outpatient department or community mental health center.
Overbite
Misalignment of the upper and lower teeth or jaws in which the upper teeth overlap the lower teeth when the mouth is closed.
Overdenture
This is a complete denture that fits over one or more natural teeth

P

Paid claims
This refers to the amounts paid to providers or members for eligible services.
Paid to date
For a spending account, this is the amount taken from your account to pay medical expenses as of a certain date.
Palate
The roof of the mouth.
Palliative
Palliative treatments are services that are intended to relieve pain but not provide a cure.
Panorex
Out-of-mouth film that provides a continuous view of the teeth and associated structures. It is used for orthodontics and the detection of fractures, TMJ, cysts, and tumors.
Part D (Medicare prescription drug coverage)
See the definition for Medicare Part D (prescription drug coverage).
Part A
See the definition for Medicare Part A (Hospital Insurance).
Part B
See the definition for Medicare Part B (Medical Insurance).
Part C (Medicare Advantage plans)
See the definition for Medicare Part C (Medicare Advantage Plans).
Partial denture
Prosthesis replacing one or more, but less than all, of the natural teeth; it may be removable or fixed.
Participating hospitals
For people with Medicare Parts A and B, these are hospitals that participate in the Medicare program.
Participating physician or supplier
For people with Medicare Parts A and B, this is a doctor or other provider who agrees to accept all Medicare claims. These providers accept "Medicare assignment." They may bill you only for the Medicare deductible and your coinsurance or copayment amounts.
Participating provider
Any provider who is a member of a benefit plan's network is considered a participating provider.
Patient advocate
A patient advocate is a person who speaks on a patient's behalf and helps patients get any information or services they need.
PCA
See “Personal Care Account”.
PCA rollover balance
Remaining previous plan year's PCA balance that you were allowed to carry over for use during your current plan year. This feature is not available to all.
PCD
Primary care dentist.
PCP
See the definition for primary care physician.
PCP name
This refers to primary care physician name. In dental insurance for a DHMO, Humana uses PCD (primary care dentist).
PDP
A Prescription Drug Plan, PDP provides seniors and people with disabilities with the first comprehensive prescription drug benefit ever offered under the Medicare program for a monthly premium.
Pediatric dentist
This is a dental specialist whose practice is limited to treatment of children from birth through adolescence.
Pedodontics
This dental specialty is concerned with the prevention and treatment of dental disorders in children.
Pedodontist
See Pediatric Dentist.
Peer review
Peer reviews are evaluations of the quality and conduct of healthcare services. They are conducted by professionals with training equal to the provider who performed the treatment.
Pended
This term indicates an estimate or a claim that has been received but processing is not complete.
Pended claims
These are claims that have been submitted but not yet paid because additional information is needed.
Pending transactions
For a spending account, these are transactions either into or out of your account that have not been completely processed. Transactions may be pending because we need to verify the charge on the HumanaAccess Visa Debit Card.
Periodontal
This term refers to things pertaining to tissues supporting and surrounding the teeth.
Periodontal abscess
An infection in the gum pocket, this type of abscess can destroy hard and soft tissues.
Periodontal disease
Inflammation of the gums and/or periodontal membrane of the teeth is considered periodontal disease.
Periodontal pocket
The deep crevice produced by detachment of a part of the soft tissue from the root of the tooth.
Periodontics
This dental specialty is concerned with diseases of the gums and other supportive structures of the teeth.
Periodontist
A dental specialist, a periodontist’s practice is limited to the treatment of diseases of the supporting and surrounding tissues of the teeth.
Periodontitis
This refers to the inflammation and loss of the connective tissue of the supporting or surrounding tooth structure.
Permanent and total disability
This refers to a disability that prevents you from working again because of injury or illness.
Permanent mailing address
This is the address where you currently reside. It is considered your primary residence.
Permanent teeth
These are also known as the second teeth or adult teeth.
Personal Care Account
Personal Care Account - A Health Reimbursement Arrangement (HRA) regulated by the IRS and funded entirely by the employer. You can use PCA funds for qualified medical expenses not covered under the health plan.
Pharmacy coinsurance
This is the percentage of the total cost of your prescription drug that you must pay. When you go to an in-network pharmacy, your coinsurance is based on the Humana-approved charge, which may be less than the original charge.
Pharmacy copayment
The amount you pay for a prescription drug is your pharmacy copayment. A copayment can range from a few dollars to a few hundred dollars depending on the type of drug you receive.
Physical therapy
Exercise, massage, stretching, applied heat, and other activities are forms of physical therapy used to treat injuries or debilitating illnesses.
Physician
Medical professionals who are licensed by the country or state in which they perform or prescribe treatment, physicians can only practice within the scope of their license.
Physician Finder Plus
Here's where you can find out if your doctor is in network. Physician Finder Plus — on Humana.com/members — lets you search for in-network doctors, hospitals, urgent care centers, and other providers of healthcare.
Pit
This is a small depression in the enamel of the tooth.
Plan certificate
A document that details your benefits.
Plan pays/paid
The amount Humana will pay or has paid for a specific service.
Plan premium
A plan premium is your monthly payment to Humana for healthcare coverage or prescription drug coverage. This cost does not include your Medicare Part A or Part B premiums.
Plan year
The year starting with your plan effective date is known as your plan year.
Planing (root)
Planing refers to the scaling of the root surface to smooth the surface.
Plaque
A soft, sticky substance, plaque is composed largely of bacteria that accumulates on teeth.
POA
A Power of Attorney (POA) is a document that's signed by a member to authorize another party to act on the member's behalf. The Executor of Estate takes the place of a Power of Attorney after a member is deceased and the Executor is appointed. Power of Attorney and Executor of Estate are legal documentation and must be provided before another party can act on the member's behalf.
Point Of Service (POS)
The option under TRICARE Prime that allows enrollees to self-refer for non-emergent health care services to any TRICARE-authorized civilian provider, in or out of the network. When Prime enrollees choose to use the POS option (i.e., to obtain non-emergent health care services from other than their Primary Care Managers [PCMs] or without a referral from their PCMs), all requirements applicable to TRICARE Standard apply except the requirement for a Non-Availability Statement. POS claims are subject to deductibles and cost-shares even after the enrollment/fiscal year catastrophic cap has been met. The POS option is not available to Active Duty Service Members (ADSMs).
Point-of-service plans
These plans permit you to choose providers outside your plan but still encourage you to use network providers.
Policy
This is the legal document a benefits insurer issues to the policyholder, which outlines the conditions and terms of the benefits. It is also called the policy contract or the contract.
Policy term
The period for which a benefits policy provides coverage for eligible employees is the policy term.
Pontic
An artificial tooth used in a bridge to replace a missing tooth is a pontic.
Porcelain
In dental care, this is a restorative material of various types of fused (molten) glasses. It’s used to make teeth, facings, jackets, and dentures.
Portability
Portability is a component of HIPAA that protects coverage for workers and their families when they change or lose their jobs. It also prevents discrimination against employees and their families due to preexisting medical conditions.
Portability (Group)
Portability allows an active eligible employee who leaves the group to continue coverage by paying annual premiums to Humana if he or she is not yet age 70. Only coverage in force or a lesser amount can be ported at termination.
Portability (Voluntary Life)
Humana Voluntary Life is portable subject to plan provisions. An active eligible employee who leaves the group can continue coverage by paying annual premiums to Humana if he or she is not yet age 70. Only coverage in force or a lesser amount can be ported at termination.
Post
This is a device like a rod that is fitted and cemented within a prepared root canal. It strengthens material that restores the affected area and/or a crown.
Post and core
Single cast unit that provides strength and restores lost structure. In dental care it is placed into the tooth, followed by the permanent exterior restoration, usually a crown.
Posted transactions
For a spending account, these are transactions that have been verified and applied to your account.
Posterior
In dental care, this term refers to the back teeth (molars and bicuspids).
Power of attorney
A medical power of attorney is a document that lets you appoint someone you trust to make decisions about your medical care. This type of advance directive also may be called a healthcare proxy, appointment of healthcare agent, or a durable power of attorney for healthcare.
PPO
PPO is short for a Preferred Provider Organization, a type of health plan that gives you the freedom to choose your own doctors and hospitals. However, your out-of-pocket costs are usually lower if you choose healthcare providers who participate in the plan's network.
PPO plan
See the definition for Preferred Provider Organization (PPO).
Preauthorization
This statement by a third-party payer indicates the proposed treatment that will be covered under the terms of the contract.
Pre-certification
Pre-certification is a third-party payer's confirmation that you are eligible for coverage under a benefit program.
Pre-determination
In this process, the provider submits a treatment plan to the third-party payer before treatment is begun. In response, the third-party payer notifies the provider and patient of the covered services, benefits payable, copayments, deductibles and plan maximum.
Pre-existing condition
A condition you had and were advised of before obtaining health insurance with Humana is a pre-existing condition. In some cases, there's a waiting period before this condition will be covered by your insurance.
Preferred brand drug
This is a brand-name medication on Humana’s formulary that may be priced lower since it is preferred.
Preferred generic drug
These are drugs on your formulary that are the equivalent of brand name drugs with the same chemical makeup. These medications have the same risks and benefits as brand name versions: they are as safe, have the same active ingredients, are prescribed at the same dosages, and are used to treat illnesses in the same way. However, a generic drug is called by its "chemical" name instead of a "brand" name and is typically sold at a lower price. In most cases, your doctor can prescribe a generic drug instead of the brand-name, allowing you to save on your prescriptions.
Preferred pharmacy
This is a network pharmacy where covered Part D drugs are offered at negotiated prices with cost-sharing levels that are lower than those at non-preferred pharmacies.
Preferred provider
Providers who contract to provide health services to persons covered by a particular health plan are preferred providers.
Preferred Provider Organization - PPO (Medicare)
A PPO is a Medicare Advantage plan that gives you two ways to receive medical services. You can use doctors, hospitals, and other healthcare providers in the plan's network and pay less for your care. Or you have the option of going outside the network, but you will pay more for your healthcare services. Get more information on HumanaChoicePPO plans.
Preferred Provider Organization (PPO)
PPOs are managed care organizations that offer certain methods to deliver services, such as networks of providers. Under a PPO benefit plan, covered individuals retain the freedom to choose providers but are given financial incentives (i.e. lower out-of-pocket costs) to use the preferred provider network.
Premium (Medicare)
A premium is what you pay for healthcare coverage. Premiums are usually paid monthly to Medicare, an insurance company, or a healthcare plan.
Premolars
The bicuspid teeth immediately before the molars are the premolars.
Prepaid dental plan
This is a method of financing the cost of dental care before you receive services.
Preparation (prep) date
For dental care, this is the date the tooth is prepared for an appliance, and an impression is taken of the tooth.
Prescription drug guide
This guide is a list of the medications covered by Humana's prescription drug benefits. See the definition of drug list.
Prescription Drug Plan (PDP)
PDPs is optional Medicare drug coverage offered through private insurance companies. It is also known as Medicare Part D. You must pay a monthly premium for a PDP in addition to any Medicare premium you already pay. PDP plan benefits vary, but companies offering these plans are required to provide benefits as good as or better than Medicare's standard requirement.
Preventive care
With this type of care, there is an emphasis on preventing health problems before they occur.
Preventive services
These are dental procedures concerned with the prevention of dental diseases by protective and educational measures. They may include an examination, cleanings, X-rays, and fluoride treatments.
Preventive services (dental)
Dental procedures concerned with the prevention of dental diseases by protective and educational measures. May include examination, cleanings, X-rays, and fluoride.
Primary care
This basic level of care is usually provided by doctors or nurse practitioners who work in general and family medicine, internal medicine, prenatal medicine, and pediatrics.
Primary care doctors
Most plans consider the following doctors to provide this basic level of healthcare: general practitioner, family medicine doctor, obstetrician, pediatrician, and, sometimes, a nurse practitioner.
Primary Care Manager (PCM)
An MTF provider, team of providers, or a network provider to whom a beneficiary is assigned for primary care services at the time of enrollment in TRICARE Prime. Enrolled beneficiaries agree to initially seek all non-emergency, non-behavioral health care services from their PCMs.
Primary care physician (PCP)
Your PCP is the doctor you see first for most health problems. PCPs make sure that you get the care you need to stay healthy. They may consult with other doctors and healthcare providers about your care and refer you to them. In many Health Maintenance Organization (HMO) plans, you must see your primary care physician before you see any other healthcare provider.
Primary coverage
This refers to coverage that pays expenses first, whether or not there is any other coverage. See Coordination of Benefits.
Prime Service Area (PSA)
The geographic area where TRICARE Prime benefits are offered. This includes all catchment areas, Base Realignment, and Closure Commission sites; a 40-mile radius around all military treatment facilities; and all additional areas proposed by the regional managed care support contractor.
Prior authorization
Your doctor must obtain approval from Humana before a specific service or prescription will be covered. This is known as prior authorization.
Procedure
This is something done to fix a health problem or to learn more about your condition. Types of procedures include surgery, tests, or starting an intravenous line.
Prophy
See Prophylaxis.
Prophylaxis
This is a scaling and polishing procedure performed to remove plaque, calculus, and stains.
Prorate
To divide, distribute, or assess based on proportion.
Prosthesis
An artificial replacement of any part of the body is known as a prosthesis.
Prosthodontic services
Dental specialty concerned with the restoration of missing teeth by artificial means.
Prosthodontist
A dental specialist, a prosthodontist’s practice is limited to the restoration of the natural teeth and/or the replacement of missing teeth with artificial substitutes.
Protected Health Information (PHI)
Protected Health Information is made up of two components: Health Information and Individually Identifiable Health Information. Health Information is information that relates to the past, present, or future health of the individual; the provision of healthcare to an individual; or the past, present, or future payment for the provision of healthcare. Individually Identifiable Health Information is information that can be used to identify the individual, such as a name or social security number.
Provider
A person or facility that offers healthcare services is called a provider. Providers may include a doctor, hospital, skilled nursing facility, home health agency, outpatient physical therapy, comprehensive outpatient rehabilitation facility, end-stage renal disease facility, hospice, non-physician provider, laboratory, supplier, etc. Generally, providers are licensed or certified and must practice within the scope of their license or certification.
Provider name
The name of the treating doctor, hospital, or other healthcare provider.
Proximal
In dental care, this term refers to the surface nearest the adjacent tooth.
Pulp
Pulp is the soft inner structure of a tooth consisting of blood vessels and nerves.
Pulp (dental)
Soft inner structure of a tooth consisting of blood vessels and nerves.
Pulpectomy
Removal of either vital or inflamed pulp from the chamber and root canals.
Pulpotomy
Pulpotomy is the surgical removal of a portion of tooth pulp to maintain the health of the remaining portion of the tooth.
Purchaser
A benefit plan sponsor, a purchaser is often an employer or a union that contracts with the benefit organization to provide benefits.

Q

Quadrant
In dental care, this term refers to one-half of each dental arch.
Qualified amount
For a spending account, this is the amount you can be reimbursed for from the account, based on plan or IRS rules.
Qualified expense
For a spending account, this is the amount of a service that is reimbursable from your account based on IRS rules and your plan.
Qualified Medicare Beneficiary (QMB)
QMB is a Medicaid program for people who need help paying for Medicare services. To be a beneficiary you must have Medicare Part A and limited income and resources. If you qualify, the Medicaid program pays Medicare Part A premiums, Part B premiums, and Medicare deductibles and coinsurance amounts for your Medicare services.
Quality assessment
This is the measure of the quality of care.
Quality assurance
This is an assessment of the quality of care and any necessary changes that must be made to either maintain or improve the quality of care.
Quantity
This refers to the amount of a drug your doctor prescribes (for example, 30 tablets).
Quantity limit
Based on recommendations from the FDA, quantity limits may be set by Humana for some medications. This means you will not be able to receive more than a specified quantity of that drug within any single month.

R

Radiograph
Another term for an X-ray.
Rebase
This refers to replacing the denture base.
Recession
This is the gradual drawing away of tissue from its normal position; for example, the recession of the gum away from the tooth.
Re-credentialing
Renewing approval of a provider as a participant in the benefit plan is called re-credentialing.
Reference number
Number assigned by our computer system that serves as a confirmation number of receiving the document.
Referral
This is a written OK from your primary care physician for you to see a specialist or to receive certain services.
Regional anesthesia
See Local Anesthesia.
Reimbursement
Reimbursement is payment made by a third party to a subscriber or provider for expenses associated with services or materials.
Reline
To resurface the tissue-borne areas of a denture with new material.
Removable appliance
This refers to a space maintenance or orthodontic devices that you can remove.
Removable partial denture
Unlike permanent dentures, you can take out this artificial device, which replaces one or more missing teeth.
Renewal
Renewal is the process of continuing coverage under a policy beyond its original term with the insurer's acceptance of a premium for a new policy term.
Resin
Organic materials, resin is usually named according to chemical composition, physical structure or means of curing. It is frequently referred to as plastic.
Respite care
This is temporary or periodic care provided in a nursing home, assisted living residence, or other type of long-term care program that allows the usual caregiver to take a break.
Retail pharmacy
A licensed pharmacy where you can purchase a covered Part D drug without being required to receive medical services from a provider affiliated with that pharmacy. Mail-order pharmacies are separate from retail pharmacies.
Retainer (dental)
Appliance to prevent collapse of the dental arch.
Return to work
This is the industry-standard term for 1) the actual resumption of work by an injured employee, or 2) the process of returning an injured employee to the work setting.
Rider
A provision attached to a policy that adds or restricts benefits is a rider.
Room and board
All the services a facility provides on its own behalf are considered part of room and board. These might include use of a room, meals, and general non-medical services you might need as an inpatient.
Root canal therapy (endodontic therapy)
This treatment for a tooth with damaged pulp usually consists of removing the pulp chamber and root canals, and filling these spaces with inert sealing material.
Root planing
Smoothing of roughened root surfaces with scalers and dental instruments is root planing.
Root planning
Smoothing of roughened root surfaces with scalers and dental instruments.

S

SAMHSA
The Substance Abuse and Mental Health Services Administration is a division of the United States Department of Health and Human Services that is a certifying laboratory agency.
Scale
To remove tartar and stains from teeth with special dental instruments
Scaling
This is the removal of plaque, calculus, and stains from teeth.
Schedule of benefits
A listing of the services for which a benefit plan will pay is called the schedule of benefit
Sealant
Material applied to the chewing surface of a tooth to prevent decay.
Sealants
This is plastic placed on the biting surfaces of back teeth to prevent cavities.
Seat belt benefit
If the insured dies from injuries sustained in an automobile accident while driving or riding in a private passenger car and wearing a seat belt, Humana Life will increase the amount of the insured's benefit by 10% (but not by less than $1,000 or more than $10,000).
Seat date
Date the appliance is cemented/put in place is the seat date. For orthodontics, it is the date the bands are placed on the teeth.
Section 125 plan
This plan provides flexible benefits and qualifies under the IRS code to allow employee contributions with pre-tax dollars.
Semiprecious metals
Materials developed for dental restorations that have a lesser amount of precious metals.
Service Area
The specific county/ZIP code/state that a member actually resides in, the service area is where you must live for a plan to accept you as its member. If a member moves, he or she needs to contact Customer Care to see if the service area is affected.
Service area (Medicare)
The geographic area where a health plan accepts members is the service area. For Medicare plans that require you to use in-network doctors and hospitals, it is also the area where services are provided. The plan may disenroll you if you move out of the plan's service area.
Service code/description
Standard healthcare industry codes that doctors, hospitals, and other healthcare providers use to bill insurance companies for services. Next to each code is a shortened description to give you a general understanding of the service - for example, “office visit,” “lab work,” or “surgery.”
Service date
The date you received service from a healthcare provider. It is also referred to as the “date of service.”
Service start date
The date a particular service or procedure started.
Service stop date
The date a particular service or procedure ended.
Short-term disability insurance
A policy that pays benefits for a limited period of time (e.g., one year) is short-term disability insurance.
Silicate
Synthetic fillings other than silver, gold, or ordinary cement to set crowns, bridges, etc.
Skilled care
This is the type of healthcare provided by skilled nursing or rehabilitation staff members who are managing, observing, and evaluating your care.
Skilled nursing care
A level of care that must be given or supervised by Registered Nurses, skilled nursing care includes administering intravenous injections, tube feeding, giving oxygen, and changing sterile dressings on a wound. Any service that could be done safely by non-medical personnel without the supervision of a Registered Nurse is not considered skilled care.
Sockets
In dental care this term refers to cone-shaped cavities in the upper and lower arch, in which the teeth are embedded.
Special Enrollment Period (SEP)
During this set time period you can sign up for Medicare Part B if you did not take Part B during the Initial Enrollment Period because you had group health plan coverage through your or your spouse’s employer or union. You can enroll in Part B at any time while you are covered under the group plan. Once your existing employment or group coverage ends, you have eight months to enroll. The eight-month SEP starts the month after employment ends or the group health coverage ends, whichever comes first.
Specialist
A doctor who treats only certain parts of the body, certain health problems, or certain age groups is a specialist. For example, some doctors treat only heart problems.
Specialty drug
High-cost drugs, including high technology and self-administered injectable medications, are specialty drugs.
Specified Low-Income Medicare Beneficiaries (SLMB)
Specified SLMB is a Medicaid program that pays Medicare Part B premiums for individuals who have Medicare Part A, a low monthly income, and limited resources.
Splint
This appliance is used to prevent the motion of teeth.
Splint (dental)
Appliance to prevent motion of teeth.
Split enrollment
Split enrollment refers to multiple family members enrolled in TRICARE Prime under different TRICARE regions or managed care support contractors.
Sponsor
The sponsor is the ADSM, retiree, or deceased service member or former service member through whom family members are eligible for TRICARE.
Spouse coverage
If your spouse is eligible for another employer's health plan — but chooses to be covered by your plan — you may pay a surcharge fee to cover some of your employer's costs for insuring your spouse.
Start date
Date on which the member's coverage begins or an account becomes available. Also called the “effective date.”
Status
Informs the member if the policy is active, termed, or COBRA.
Stayplate (flipper)
This refers to an acrylic partial, with or without wire clasps, that replaces one or more teeth; usually temporary.
Stomatitis
A term that refers to inflammation of the tissues of the mouth.
Study models
These plaster models of the teeth, made from an impression, show all the teeth in the upper and lower jaws and the relationship between the teeth.
Subscriber
A person who enrolls in a Humana plan or account.
Subscriber number
Unique identifying number for a person who enrolls in a Humana plan or account.
Summary of benefits
This is a brief description or outline of your coverage, including the amounts or percentage you pay for certain services, the amounts or percentage your plan pays, and the services for which coverage is limited or excluded.
Summary Plan Description
A legal document detailing a member's or group's coverage.
Supplemental Health Care Program (SHCP)
SHCP is a program for eligible uniformed service members and other designated patients who require medical care that is not available at the MTF upon the approval of the cognizant MTF commander or the Director, TRICARE Management Activity, as required, to be purchased from civilian providers under TRICARE payment rules.
Supplier
Generally, a supplier is any company, person, or agency that gives you a medical item or service, like a wheelchair or walker.
Surgical extraction
Removal of a tooth by surgical methods is a surgical extraction.

T

Tartar
Hard deposit that forms on teeth when plaque hardens.
Temporary removable denture
This interim, artificial device is designed for use over a limited period of time.
Temporomandibular Joint (TMJ)
TMJ is the hinge between the base of the skull and the lower jaw.
Temporomandibular joint (TMJ)
Joint between the skull and the mandible.
Temporomandibular joint dysfunction
This refers to abnormal functioning of temporomandibular joint.
Term life insurance
This is insurance that provides death benefit protection for a specified length of time and pays benefits only if the insured dies while the term insurance is in force.
Termination date
The date on which the contract expires or the date an individual ceases to be eligible for benefits. Is the termination date
Terms and conditions of payment (PFFS Plans)
Any Medicare doctor, specialist, or hospital that accepts Medicare payment must also accept the terms, conditions, and payment rate of the Humana Gold Choice (PFFS) plan.
Therapeutic alternative
Some drugs are designated therapeutic alternatives. These medications are not exactly the same as another drug, but can serve as a substitution with the full expectation that they will be as safe as the prescribed medication and will produce the same clinical effect.
Third-Party Administrator (TPA)
An organization or individual contracted by a self-insured employer or insurance company to handle the administration and, in some cases, the payment of claims. Also referred to as TPA.
Time limit
The period of time during which a claim must be filed.
TMJ syndrome
These are symptoms associated with malfunction of the temporomandibular joint.
Torus
A projection or overgrowth of bone.
Total amount plan pays
The amount Humana paid on a claim.
Total charge
The amount billed to Humana by your doctor, hospital, or other healthcare provider for a claim.
Totally disabled
You are considered totally disabled if injury or sickness has left you unable to perform your occupation or any occupation for which you are fit by reason of education, training, or experience.
Transaction date
For a spending account, this is the date you provided your HumanaAccess Card for payment or submitted a claim for reimbursement.
Transaction ID
The number that uniquely identifies the claim or transaction. Customer Care can use this number to track your claim if you have questions.
Transaction type
For a spending account, this term refers to the service or procedure you received.
Transitional Assistance Management Program (TAMP)
TAMP provides 180 days of transitional health care benefits to help certain uniformed services members and their families transition to civilian life.
Transitional care
Transitional care is designed for all beneficiaries to ensure a coordinated approach takes place across the continuum of care.
Translator
This is someone who translates the enrollment documentation for the enrollee and who is fully competent in both English and the enrollee's native language.
Treatment
Something done to help with a health problem (such as administering medicine or performing surgery) is considered treatment.
TRICARE
TRICARE is the Department of Defense's worldwide healthcare program for active duty and retired uniformed services members and their families. TRICARE For Life is available for all dual TRICARE-Medicare-eligible uniformed services retirees and Medicare-eligible family members under age 65 who are also entitled to Medicare Part A because of a disability or chronic renal disease.
TrOOP (True Out-of-Pocket Costs)
These Annual out-of-pocket-costs include all payments for covered Part D drugs paid by you or by others on your behalf. Once you reach the defined annual threshold, you move on to the Catastrophic Coverage stage of your Medicare Part D plan.

U

Underwriter
This person identifies and calculates the risk of loss from policyholders, establish premium rates, and write policies to cover the risks.
Unerupted
This term is used in dental care to mean something has not come through the gums.
Unilateral
Something unilateral involves only one side.
Urgent care center
Urgent care — also called walk-in — centers provide a good medical and financial alternative when you can't see your regular doctor and your illness or injury is relatively minor. Urgent care centers have shorter waits, don't require an appointment, are open evenings and weekends, and cost less than an emergency room.
Urgently needed care
This is care you receive for a sudden illness or injury that, while not life threatening, requires immediate medical attention. This care should be provided by your primary care physician unless you are out of the service area.
Usual and customary
This refers to a fee amount that is the maximum amount to be paid for a specific procedure.
Usual, Customary, and Reasonable (UCR)
UCR refer to the commonly charged fees for services within a geographic area.

V

Valid receipts
For a spending account, a valid receipt must show what the charge is for AND when you incurred the charge. Examples an itemized receipt, bill, or invoice; an EOB; or a written statement from a third party. Receipts that are NOT valid include copies of cancelled checks or statements showing only a balance forward or a total charge.
Value-added services
Extra services you get through a Medicare Advantage or Medicare prescription drug plan in addition to your plan benefits are considered value-added services.
Veneer
In the construction of crowns or bridges, this is a layer of tooth-colored material.
Veneer crown
A full crown, which has one or more surfaces, covered by tooth-colored plastic or porcelain.
Vitality test
This test uses thermal, electrical, or mechanical stimuli to determine the vitality of the dental pulp.
Vitality test (dental)
Test using thermal, electrical, or mechanical stimuli to determine the vitality of the dental pulp.
Voluntary life insurance
Insurance for which the employee pays the entire monthly premium based on the group's characteristics is voluntary life insurance.
Voluntary plan
Insurance plan that employers can offer at no cost to their business. Employees like the simplicity and convenience of having their premiums deducted directly from their paychecks.
Voluntary plans
A comprehensive dental insurance plan that employers can offer at no cost to their business is known as a voluntary plan.

W

Waiting period
This is the period between employment or enrollment in a dental plan and the date when a covered person becomes eligible for benefits. Services subject to a waiting period could be crowns, bridges, or orthodontics.
Waiting period (Medicare)
This is the time between when you sign up with a Medicare plan and when the coverage starts.
Waiting period days remaining
This refers to the time remaining before the waiting period expires
Waiver of premium
This provision continues insurance coverage without further premium payments if the insured is totally disabled.
Witness
If you are visually impaired or speech impaired, a witness can participate in the enrollment process with you to confirm that you have understood the information to the best of your knowledge.
Workers’ compensation
Provision for payment of benefits to workers for accidental injuries or death arising from, and in the course of, employment.

X

X-ray
A form of radiation that produces a shadowy negative, which provides a means of diagnostic dental evaluation. The following terms are examples of dental X-rays taken
X-ray (dental)
A form of radiation that produces a shadowy negative, which provides a means of diagnostic evaluation.

Y

You pay
This refers to your projected out-of-pocket costs for prescription drugs in a particular category, or "tier." This might include copayments, coinsurance, and any amount over and above a given prescription allowance.
You pay/paid
The estimated member responsibility, which is the dollar amount you are responsible for paying out of your own pocket for a claim. This amount may include deductible, copayment, coinsurance, and/or other non-covered services.