Supervising the details and routine activities of installing and running a health plan, such as answering questions, enrolling individuals, billing and collecting premiums, and similar duties.

A mathematician, working for a health insurance company, who is responsible for determining what premiums the company needs to charge based in large part on claims paid versus amounts of premium generated. Their job is to make sure a block of business is priced to be profitable.

A specific situation, condition or treatment that a health insurance plan does not cover or limits in coverage. This will be stipulated by the insurance Company.

Approval by a case manager or insurance company representative for a person to be admitted to a hospital or in-patient facility, granted prior to the admittance. Pre-certification often must be obtained by the individual. The goal of pre-certification is to ensure that individuals are not exposed to inappropriate health care services (services that are medically unnecessary).

Any activity carried out to help a person/group to get something the person/group needs or wants.

A written or electronic statement which gives details about how a claim was paid by the insurer. It will contain information of what was paid to you and/or the provider, and the portion of the costs you are responsible for.

Medical tests that are completed for an individual prior to being admitted to a hospital or inpatient health care facility.

Salespersons who represent one or more health insurance companies and presents their products to consumers.

A “twin” to a “brand name drug” once the brand name company’s patent has run out and other drug companies are allowed to sell a duplicate of the original. Generic drugs are cheaper, and most prescription and health plans reward clients for choosing generics.

The services & amounts payable by the insurance company.