Coverage Limitations

Limits in what healthcare services or providers are covered under a specific plan. The more limitations on coverage, the lower the cost to the patient (generally).

Current Procedural Terminology (CPT)

A standardized list of medical procedures and services. Similar to the ICD-10 system, CPT codes classify procedures completed and services rendered so that a professional may be paid accordingly by an insurer. Often five digits long, ranging from 00100 to 99499.

Decline

A company's refusal to accept the request for insurance coverage.

Deductible

The amount you owe for health care services before your health insurance plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve paid your $1000 deductible for covered health care services. The deductible may not apply to all services.

Diagnosis-Related Group (DRG)

Groups of related diagnoses grouped together by Medicare to determine hospital payment. More intensive DRGs (surgery) correspond to increased payments from Medicare to the hospital, while less intensive DRGs (fever) correspond to decreased payments. Called Ambulatory Payment Classifications (APCs) in the non-hospital (clinic) setting.

Discharge Planning

A service provided by a hospital to help patients continue their medical care once they have left the hospital (in the outpatient setting). This may involve coordinating between a primary care physician, a specialty physician, physical/occupational therapy, nursing services, and the like.

Disease Management Program

A program coordinating patient care between multiple medical professionals in which patients are often on strict and closely monitored medication regimens.

Dual-eligible Beneficiary

A person who is eligible for both Medicare (by age or disability) and Medicaid (by income).

Durable Medical Equipment (DME)

Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches, blood testing strips for diabetics, and more.

Emergency Medical Treatment and Labor Act (EMTALA)

An act that requires hospitals to stabilize or transfer patients if they present with a true emergency, regardless of ability to pay. Services may still be billed after the patient is stabilized. Patients can seek to negotiate prices or apply for Medicaid (if they qualify).

Emergent Medical Condition

An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.

Emergent Medical Transportation

Ambulance services for an emergency medical condition.