Glossary
Plain-language definitions for the words health care and insurance throw at you — deductible, coinsurance, prior authorization, and more. Jump to a letter or skim the list.
A
- Allowed amount
- The most your plan will pay for a covered service — the rate it negotiated. You may owe a share of it, but usually not more.
- Ancillary services
- Support services that go with your main care — like lab tests, imaging, or anesthesia — sometimes billed separately by a different provider.
- Appeal
- A formal request asking your insurer to reconsider a denied claim. Many denials are overturned.
B
- Balance billing
- When an out-of-network provider bills you for the difference between their charge and what your plan paid. The No Surprises Act limits this in many cases.
C
- Cash-pay
- Paying the provider directly instead of using insurance — often at a lower, upfront price, especially before you have met your deductible.
- Chargemaster
- A hospital's master list of list prices for services. These prices are high and are what insurers negotiate discounts from — they are rarely what anyone actually pays. Example: The chargemaster price for a scan can be many times the cash-pay price.
- Claim
- A request your provider sends to your insurer to be paid for the care you received.
- Coinsurance
- The share of a covered cost you keep paying after you meet your deductible, written as a percent. Your plan pays the rest. Example: With 20% coinsurance, you pay $20 of every $100 in covered care and the plan pays $80.
- Concussion
- A mild traumatic brain injury from a blow or jolt to the head. Symptoms can include headache, dizziness, and trouble concentrating; most people recover with proper rest and follow-up care. Example: After a sports concussion, a structured return-to-play plan helps recovery.
- Copay
- A flat fee you pay for a specific service, like a doctor visit or a prescription. It can apply even before you meet your deductible.
- CT scan
- A test that combines many X-ray images into detailed cross-section pictures of bones and tissues; it is fast and especially good for bone detail. Example: A CT scan can show a complex fracture in fine detail.
D
- Deductible
- The amount you pay out of pocket each year before your plan starts sharing most costs. Until you reach it, you usually pay the full negotiated price for covered care. Example: With a $2,000 deductible, you pay the first $2,000 of covered care yourself before coinsurance begins.
- Denial
- When your insurer refuses to pay a claim. You usually have the right to appeal.
- Direct contracting
- Paying an agreed, bundled price directly to the provider, skipping insurance billing.
E
- Explanation of Benefits (EOB)
- A summary from your insurer showing what was billed, what the plan paid, and what you may owe. It is not a bill.
F
- Facility fee
- A separate charge for using a hospital or hospital-owned space, added on top of the provider's fee — a common reason the same service can cost more in some settings. Example: The same test cost more at the hospital because of a facility fee.
- Flexible Spending Account (FSA)
- An employer account that lets you set aside pre-tax money for medical costs. Funds usually must be used within the plan year.
- Formulary
- The list of medicines your plan covers, often grouped into price tiers.
- Functional Capacity Evaluation (FCE)
- A hands-on test of what you can physically do — lifting, strength, endurance — used to set safe work restrictions after an injury. Example: An FCE might show you can lift 20 pounds occasionally, which shapes your return-to-work plan.
G
- Good Faith Estimate
- A written estimate of what care will cost if you do not use insurance. Providers must give one to self-pay patients on request.
H
- Health Savings Account (HSA)
- A tax-advantaged account for medical costs, paired with a high-deductible plan. The money stays yours year to year.
- High-Deductible Health Plan (HDHP)
- A plan with a lower monthly premium but a higher deductible. It can be paired with an HSA.
I
- Impairment rating
- An estimate, given as a percentage after Maximum Medical Improvement, of any lasting loss of function from an injury, measured with standard medical guidelines (often the AMA Guides). Example: A 5% impairment rating to the knee helps set the value of a permanent-injury benefit.
- In-network
- Providers and facilities that have a contract with your plan, usually at lower negotiated prices.
- Independent Medical Exam (IME)
- A one-time exam by a doctor who is not treating you, usually requested by an employer, insurer, or attorney to give an opinion on an injury, treatment, or work restrictions. Example: An insurer may schedule an IME to get a second view of your work restrictions.
- Interventional pain management
- A specialty that treats pain with targeted procedures — such as injections or nerve treatments — often to reduce the need for surgery or long-term medication. Example: An epidural steroid injection is a common interventional pain treatment.
- Itemized bill
- A line-by-line list of every charge for your care. You can request one to check a bill for errors before you pay. Example: An itemized bill let her spot a duplicate charge and get it removed.
M
- Maximum Medical Improvement (MMI)
- The point in recovery when your condition has stabilized and is not expected to improve much more, even with further treatment. It is a milestone — not always full recovery — used to decide next steps in a workers' comp claim. Example: After surgery and rehab, a doctor may declare MMI, which lets the claim move to deciding any lasting impairment.
- MRI
- Magnetic Resonance Imaging — an imaging test that uses strong magnets and radio waves (no X-ray radiation) to make detailed pictures of soft tissues such as muscles, ligaments, and spinal discs. Example: An MRI can show a torn ligament that an X-ray would miss.
N
- Network
- The group of providers and facilities your plan contracts with. Staying in-network usually costs you less.
- No Surprises Act
- A federal law that protects you from many surprise out-of-network bills — especially for emergency care and for out-of-network providers treating you at an in-network facility. Example: The No Surprises Act can stop a surprise bill from an out-of-network anesthesiologist.
- Nurse practitioner (NP/APRN)
- A registered nurse with advanced graduate training who can examine patients, diagnose, order and interpret tests, and prescribe medication. Example: Seeing an NP often means you can be seen sooner for routine care.
O
- Orthopedics
- The branch of medicine focused on bones, joints, muscles, ligaments, and tendons — including injuries, arthritis, and surgery such as joint replacement. Example: An orthopedic specialist treats a torn rotator cuff.
- Out-of-network
- Providers without a contract with your plan. Your costs are usually higher, and some plans do not cover them at all.
- Out-of-pocket maximum
- The most you will pay for covered, in-network care in a year. After you reach it, your plan pays 100% of covered costs.
P
- Physical therapy (PT)
- Guided exercise and hands-on treatment that helps you recover movement and strength, and often helps you avoid or delay surgery. Example: A few weeks of PT can relieve back pain without surgery.
- Physician (MD/DO)
- A medical doctor — "MD" or "DO" — with four years of medical school plus a multi-year residency in a chosen field. Example: More complex or surgical cases are usually directed to a physician.
- Physician assistant (PA)
- A clinician trained in a graduate medical program who can examine, diagnose, order tests, and prescribe, working as part of the care team. Example: A PA can handle many everyday and follow-up visits.
- Preferred provider
- A doctor or facility in your plan’s network that you usually pay less to see. The "PPO" in plan names stands for Preferred Provider Organization.
- Premium
- What you pay every month just to have the plan, whether or not you use any care.
- Primary care
- Everyday, first-stop medical care for general health, prevention, and common problems, often from a family or general provider. Example: Your primary care provider coordinates referrals to specialists.
- Primary care provider (PCP)
- Your main, go-to clinician for everyday health — checkups, common illnesses, and coordinating the rest of your care. A PCP can be a physician, NP, or PA. Example: Your PCP keeps track of your overall care and refers you to specialists.
- Prior authorization
- Your insurer's approval before it will cover certain care, tests, or medicines. Without it, the claim can be denied.
- Provider
- Anyone licensed to give you medical care — a physician, nurse practitioner, or physician assistant. Clinics use "provider" as a catch-all for whoever is caring for you. Example: A form that says "see your provider" just means the clinician taking care of you.
R
- Referral
- A recommendation from one provider to see a specialist. Some plans require one before they will cover the specialist visit.
- Release of medical records
- Your written permission for a provider to share your medical records with you or another party. You have the right to get a copy of your own records. Example: Signing a records release lets a new specialist see your imaging.
S
- Second opinion
- Asking another qualified provider to review your diagnosis or treatment plan so you can make a more confident decision, especially before surgery or other major care. Example: Getting a second opinion before back surgery is a reasonable, common step.
- Specialist
- A provider who focuses on one area of medicine, such as orthopedics, cardiology, or neurology. You often reach a specialist through a referral. Example: A knee injury might send you to an orthopedic specialist.
- Sports medicine
- Care focused on preventing, diagnosing, and treating injuries related to activity and exercise — for athletes and non-athletes alike. Example: A sports-medicine provider manages a runner's knee injury.
T
- Telehealth
- A medical visit done by phone or video instead of in person — convenient for everyday concerns and follow-ups. Example: A telehealth visit can sort out a minor issue without a trip to the clinic.
- Temporary Total Disability (TTD)
- Wage-replacement benefits paid while a work injury keeps you completely off work for a time, before you reach Maximum Medical Improvement. Example: TTD may replace part of your wages while you recover and cannot work at all.
U
- Ultrasound
- An imaging test that uses sound waves (no radiation) to view soft tissues, tendons, and blood flow in real time. Example: Ultrasound can guide a precise injection into a joint.
- Urgent care
- Walk-in care for injuries and illnesses that need prompt attention but are not emergencies; it is usually faster and lower cost than an emergency room. Example: A sprained ankle is often best handled at urgent or walk-in care.
X
- X-ray
- A quick imaging test that uses a small amount of radiation to show bones and check for fractures or alignment problems. Example: An X-ray is usually the first imaging step after a fall.