Emergent Services

Evaluation of an emergent medical condition and treatment to keep the condition from getting worse.

Essential Health Benefits

Minimum coverage standards established by the Affordable Care Act for individual and small group plans. There are ten essential health benefit categories, including ambulatory care, emergency services, maternity care, mental health and substance use disorder treatment, prescription drugs, rehab services, lab services, preventative care, and pediatric care.

Evaluation and Management (E/M)

A type of CPT code recorded by a medical professional corresponding to the severity of a patient visit and time spend face-to-face with that patient. Ranges from 99201 (simple and short) to 99205 (complex and long). Used in the billing process by insurers.

Evidence of Coverage (EOC)

An insurance document listing the terms of a certain insurance plan akin to a contract. Varies by plan. Insurers reference the EOC to determine if a benefit is covered or denied by a specific plan. Also called a certificate of coverage (COC).

Exclusive Provider Organization (EPO)

A plan that restricts the professionals a patient can see in exchange for a lower deductible. Out of network costs are generally not covered. Similar to HMOs, but a primary care referral for specialty services is often not required.

Experience Rating

A premium set based on healthcare costs for an individual or a group of related people (for example, all people with diabetes or high blood pressure)

Expiration Date

The date on which a policy ends

Explanation of Benefits (EOB)

A document provided by an insurer to a patient and her medical professional in response to the filing of a claim. Often includes type of service, charges from the professional, amount paid by the insurer, and what the patient still owes out of pocket. Is not an official bill and is often sent out months after the patient received medical care.

Facility Fee

Fee paid by an insurer to a healthcare facility for a patient's use of the grounds. Often uses the Per Diem payment model. For example, if you stay in the hospital three days for surgery, your insurer will pay a per diem facility fee for your three days of "hospital rent."

Fee Schedule

A list of prices for a medical service, either negotiated by private insurers or administered by public insurers. Used in the Fee-For-Service payment model.

Fee for Service

A negotiated rate paid from insurance providers to healthcare professionals after care has been provided. Not prepaid. Utilized by PPOs. For example, if you see your doctor for a flu shot, your insurance company pays separate fees to the doctor for their consultation and the shot itself.

Formulary

A list of medications covered by a specific insurance plan. A classic four-tiered formulary offers the lowest copayments for generic drugs (tier one), higher copayments for discounted brand drugs (tier two), higher copayments for non-preferred brand drugs (tier three), and the highest payments for expensive drugs such as biologics (tier four). Formularies can be found online or within a Summary of Benefits and Coverage.