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AMDA-IMIC

Insurance and billing

Seguro médico y facturación

This page lists the 210 terms of the US medical glossary that belong to this area, grouped by kind. Each line gives the English term, its Spanish equivalent and a one-line definition; the term's own page adds seven more languages, example sentences for an appointment and its sources. Terms are placed in this area by their glossary category: insurance, billing, costs and administration.

Insurance (149)

ACA (Affordable Care Act) — ACA (Ley de Cuidado de Salud Asequible)
The Affordable Care Act (ACA), signed into law in 2010, is the major US health reform legislation that expanded insurance coverage through multiple mechanisms: the Health Insurance Marketplace with income-based subsidies, Medicaid expansion in participating states, requirements for coverage of pre-existing conditions, prohibition on lifetime and annual benefit limits, extension of dependent coverage to age 26, and requirements for coverage of essential health benefits and preventive services without cost-sharing.
ACA Section 2709 — Sección 2709 de la ACA
Section 2709 of the Affordable Care Act requires most private health insurance plans to cover routine patient costs—such as doctor visits, lab tests, and imaging—when you participate in an approved clinical trial for cancer or another serious, life-threatening condition.
Actuarial Value — Valor Actuarial
Actuarial value is the percentage of total covered medical costs that a health plan pays for an average patient.
Allowed Amount — Monto permitido
The allowed amount is the maximum dollar amount your insurance plan agrees to pay for a covered service or item.
Annual Notice of Change — Aviso anual de cambios
The Annual Notice of Change (ANOC) is a document Medicare Advantage and Medicare Part D plan members must receive each September, before the open enrollment period.
Appeal — Apelación
An appeal is a formal request asking your health insurance company, employer health plan, or government program to reverse a decision to deny, reduce, or end coverage for a medical service, claim, or prescription.
Appeals Process — Proceso de apelación
The appeals process is the formal procedure for challenging an insurance company's denial of a claim or a request for coverage.
APTC (Advanced Premium Tax Credit) — Crédito Fiscal Anticipado de Prima
The Advanced Premium Tax Credit (APTC) is a federal subsidy that helps eligible individuals and families pay for health insurance purchased through the Marketplace.
Assignment of Benefits — Cesión de beneficios
Assignment of benefits is your written permission allowing your insurance company to pay your provider directly instead of sending reimbursement to you.
Authorization — Autorización
Authorization (also called prior authorization or precertification) is formal approval from your insurance plan before you receive certain medical services, procedures, or medications.
Authorized Representative — Representante Autorizado
An authorized representative is a person you formally designate to act on your behalf when dealing with your health insurance company or a government health program such as Medicare or Medicaid.
Balance Billing — Cobro de saldo
Balance billing happens when an out-of-network provider charges you the difference between what your insurer paid and the provider's full billed amount.
Benefits Summary (EOB) — Resumen de Beneficios
See EOB — Explanation of Benefits.
Billable Code — Código facturable
A billable code is a diagnosis or procedure code that is sufficiently specific to be submitted on a medical insurance claim.
Binding Decision — Decisión Vinculante
A binding decision is a final ruling issued by an independent external review organization or an arbitrator that your insurance company is legally required to follow.
Bundled Payment — Pago agrupado
A bundled payment is a single combined payment made to cover all healthcare services related to a specific treatment, episode of care, or condition — such as a knee replacement — rather than paying each provider separately.
Capitation — Capitación
Capitation is a payment model in which a health plan pays a fixed monthly amount per enrolled patient to a provider or medical group — regardless of how many services that patient actually uses.
Catastrophic Coverage — Cobertura Catastrófica
A catastrophic health plan is a type of ACA marketplace plan designed for people who want protection against worst-case medical costs but are willing to pay most routine expenses out of pocket.
Catastrophic Plan — Plan catastrófico
A catastrophic health plan is a type of ACA-compliant health insurance with very low monthly premiums and a very high annual deductible — equal to the ACA's out-of-pocket maximum limit (over $9,000 for an individual in 2024).
CHIP (Children's Health Insurance Program) — CHIP (Programa de Seguro de Salud para Niños)
CHIP (Children's Health Insurance Program) provides low-cost health coverage to children in families that earn too much to qualify for Medicaid but cannot afford private insurance.
Claims Adjudication — Resolución de reclamaciones
Claims adjudication is the process an insurance company uses to review, evaluate, and decide whether to pay, partially pay, or deny a submitted medical claim.
COBRA Continuation Coverage — Cobertura de Continuación COBRA
COBRA (Consolidated Omnibus Budget Reconciliation Act) allows workers and their families to continue employer-sponsored group health coverage for a limited period after leaving a job or experiencing other qualifying events such as reduced hours, divorce, or death of the covered employee.
COBRA Election Period — Período de Elección COBRA
The COBRA election period is the 60-day window after losing employer-sponsored coverage (or receiving the COBRA election notice) during which an eligible employee or dependent can choose to continue their group health coverage under COBRA.
Coinsurance — Coseguro
Coinsurance is the percentage of costs you pay for a covered service after you have met your deductible.
Concurrent Review — Revisión concurrente
Concurrent review is a type of utilization review conducted by your insurer while you are actively receiving care, most often during a hospital stay.
Continuous Eligibility — Elegibilidad Continua
Continuous eligibility is a policy under Medicaid and the Children's Health Insurance Program (CHIP) that allows eligible children—and in some states, adults—to remain enrolled in their program for a full 12 months without losing coverage due to changes in family income or circumstances during that period.
Coordination of Benefits — Coordinación de beneficios
Coordination of benefits (COB) is a process used when a patient is covered by more than one health insurance plan.
Copayment (Copay) — Copago
A copayment is a fixed dollar amount you pay for a covered healthcare service, such as a doctor visit or prescription, at the time of service.
Cost Sharing — Costo compartido
Cost sharing refers to the portion of covered health care costs that you, the patient, pay out of pocket rather than your insurer.
Cost-Sharing Reduction — Reducción de costos compartidos
A cost-sharing reduction (CSR) is a federal subsidy that lowers the amount eligible lower-income individuals and families pay out-of-pocket when they use health insurance.
Covered Service — Servicio cubierto
A covered service is any medical service, procedure, drug, or supply that your health insurance plan will pay for, at least in part, when medical necessity and other plan requirements are met.
Creditable Coverage — Cobertura Acreditable
Creditable coverage refers to prescription drug or health coverage that is at least as good as Medicare's standard coverage for the same benefit type.
Crossover Claim — Reclamación cruzada
A crossover claim is a medical claim that is automatically forwarded from Medicare (the primary payer) to Medicaid (the secondary payer) after Medicare has processed it.
Deductible — Deducible
A deductible is the amount you pay out of pocket for covered health services before your insurance begins to share costs.
Deemed Exhaustion — Agotamiento Presunto
Deemed exhaustion is a legal status that allows you to skip your health plan's internal appeal process and request external review immediately, when your insurer has failed to follow required federal or state appeal rules.
Denial Notice — Aviso de Denegación
A denial notice is a written communication from your health insurance company or government health program stating that a claim, coverage request, or prior authorization has been denied—either fully or partially.
Dependent — Dependiente
A dependent is a family member listed on your health insurance policy who receives coverage through your plan rather than their own.
Diagnosis Code — Código de diagnóstico
A diagnosis code identifies a patient's medical condition on insurance claims and clinical records.
Disenrollment — Desinscripción
Disenrollment is the process of leaving or being removed from a health insurance plan.
Downcoding — Reducción de código
Downcoding occurs when an insurance company changes a medical billing code submitted by a provider to a less complex or lower-paying code, reducing the payment the provider receives.
Dual Coverage — Cobertura dual
Dual coverage means you are enrolled in two separate health insurance plans at the same time — for example, your own employer's plan and your spouse's employer plan.
Dual-Eligible (Medicare and Medicaid) — Doble Elegibilidad (Medicare y Medicaid)
Dual-eligible individuals qualify for both Medicare and Medicaid.
Eligibility Condition — Condición de Elegibilidad
An eligibility condition is a specific requirement—often a diagnosed medical condition—that you must meet before participating in a program or receiving a particular benefit.
Eligibility Criteria — Criterios de Elegibilidad
Eligibility criteria are the formal rules that define who may enroll in or benefit from a health plan, government program, or clinical trial.
Employer-Sponsored Insurance — Seguro Patrocinado por el Empleador
Employer-sponsored insurance (ESI) is health coverage provided through a place of employment.
Episode of Care — Episodio de atención
An episode of care refers to all the healthcare services a patient receives for a specific health condition or medical event within a defined period — from the initial encounter through recovery.
EPO (Exclusive Provider Organization) — Organización de Proveedores Exclusivos
An EPO (Exclusive Provider Organization) combines features of HMO and PPO plans.
Evidence of Coverage — Evidencia de Cobertura
An evidence of coverage (EOC) is a detailed document from your health plan describing all aspects of your coverage for the plan year.
Excludes 1 Note — Excluye 1
An Excludes 1 note in ICD-10-CM means the excluded condition cannot occur with the code being referenced — these are mutually exclusive conditions.
Excludes 2 Note — Excluye 2
An Excludes 2 note in ICD-10-CM means the excluded condition is not included in the referenced code, but both conditions may be present in the same patient simultaneously.
Expedited Appeal — Apelación Expedita
An expedited appeal is a fast-track insurance appeals process available when your situation is urgent enough that waiting the standard 30-day review period could seriously jeopardize your health.
External Review — Revisión Externa
External review is an independent, binding evaluation of your health insurer's denial by an outside organization not affiliated with the plan.
Fee Schedule — Tabla de honorarios
A fee schedule is a complete list of maximum reimbursement amounts that an insurance plan or government program (like Medicare) will pay for each specific medical service, identified by procedure code.
FSA (Flexible Spending Account) — Cuenta de Gastos Flexibles
A Flexible Spending Account (FSA) is an employer-sponsored pre-tax benefit account used to pay for eligible medical, dental, and vision expenses.
FSA-Eligible Expense — Gasto Elegible para FSA
An FSA-eligible expense is a medical, dental, or vision cost that qualifies for payment using Flexible Spending Account funds.
Full Premium — Prima Completa
The full premium is the total monthly cost of a health insurance plan before any employer contribution, government tax credit, or cost-sharing reduction is applied.
General Enrollment Period — Período de Inscripción General
The General Enrollment Period (GEP) runs from January 1 through March 31 each year and allows you to sign up for Medicare Part A or Part B if you missed your Initial Enrollment Period and do not qualify for a Special Enrollment Period.
Global Period — Período global
The global period is the specific number of days around a surgery during which routine follow-up care by the operating surgeon is considered part of the original surgical fee and not billed separately.
Grace Period — Período de gracia
A grace period is a set amount of time after your health insurance premium payment due date during which your coverage remains active even if you have not yet paid.
Grievance — Queja Formal
A grievance is a formal complaint you file with your health insurance plan about a non-coverage issue—such as poor customer service, difficulty scheduling appointments, long wait times, or problems getting prescription refills.
Group Health Plan — Plan de salud grupal
A group health plan is health insurance offered by an employer or another organization — such as a union — to its employees or members and their eligible dependents.
HCPCS — HCPCS
The Healthcare Common Procedure Coding System (HCPCS, pronounced "hick-picks") is a set of codes used to bill Medicare, Medicaid, and other US health plans.
HDHP (High-Deductible Health Plan) — Plan de Alta Deducible
A High-Deductible Health Plan (HDHP) has higher deductibles and lower premiums than traditional plans.
Health Insurance Marketplace — Mercado de Seguros de Salud
The Health Insurance Marketplace (also called the Exchange) is a platform created by the ACA where individuals and families can compare and purchase ACA-compliant health insurance plans.
Health Reimbursement Arrangement — Acuerdo de reembolso de salud
A Health Reimbursement Arrangement (HRA) is an employer-funded account that reimburses employees for qualified medical expenses and sometimes health insurance premiums.
High-Deductible Health Plan — Plan de Salud con Deducible Alto
A High-Deductible Health Plan (HDHP) is a health insurance plan whose deductible meets IRS minimum thresholds—at least $1,650 for self-only coverage in 2025.
HMO (Health Maintenance Organization) — Organización de Mantenimiento de Salud
An HMO (Health Maintenance Organization) is an insurance plan type that requires members to choose a primary care provider and obtain referrals to see specialists.
HSA (Health Savings Account) — Cuenta de Ahorros para la Salud
A Health Savings Account (HSA) is a tax-advantaged savings account available to individuals enrolled in a qualifying HDHP.
HSA-Eligible Expense — Gasto Elegible para HSA
An HSA-eligible expense is a medical cost that qualifies for tax-free payment or reimbursement from a Health Savings Account.
ICD-10-CM — CIE-10-CM
The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) is the US standard code set for diagnosis reporting on medical claims.
Identification — Identificación
In healthcare, identification refers to documents—such as a driver's license, passport, state ID card, or insurance card—that providers and insurers require to confirm who you are and verify your eligibility when you register for services.
Immigration Status — Estado Migratorio
Immigration status is your legal classification under federal law—such as U.S. citizen, lawful permanent resident, refugee, asylum seeker, or undocumented immigrant—which directly affects your eligibility for federal health programs.
In-Network Provider — Proveedor en Red
An in-network provider is a doctor, hospital, pharmacy, or other healthcare provider that has a contract with your insurance plan to provide services at negotiated rates.
Income-Based Eligibility — Elegibilidad por Ingresos
Income-based eligibility means that whether you qualify for a health program—such as Medicaid, CHIP, or an Advance Premium Tax Credit on the ACA marketplace—depends on your household income measured as a percentage of the Federal Poverty Level (FPL).
Indemnity Insurance — Seguro de indemnización
Indemnity insurance (also called fee-for-service insurance or traditional health insurance) allows you to visit any doctor or hospital without a network restriction.
Independent Review Organization — Organización de Revisión Independiente
An Independent Review Organization (IRO) is an accredited third-party company that conducts external reviews of health plan coverage denials after you have exhausted internal appeals.
Initial Enrollment Period — Período de Inscripción Inicial
The Initial Enrollment Period (IEP) is the seven-month window during which you first become eligible for Medicare.
Insurance Claim — Reclamación de Seguro
An insurance claim is a formal request submitted to an insurer for payment of a covered health service.
Internal Appeal — Apelación Interna
An internal appeal is a formal request you submit to your health insurance plan asking it to reconsider a denial of coverage, prior authorization, or payment.
IRMAA — IRMAA
IRMAA stands for Income-Related Monthly Adjustment Amount—the extra surcharge added to your Medicare Part B and Part D premiums when your income from two years ago exceeds certain IRS thresholds.
Letter of Medical Necessity — Carta de necesidad médica
A letter of medical necessity is a document written by your physician explaining why a specific treatment, medication, device, or service is medically required for your condition.
Level of Care — Nivel de atención
Level of care refers to the intensity and type of medical or behavioral health services a patient needs, ranging from primary preventive care to emergency or intensive care.
Life-Changing Event — Evento que Cambia la Vida
A life-changing event (LCE) is a significant personal or financial occurrence—such as retirement, divorce, death of a spouse, marriage, loss of income-producing property, or loss of employer pension income—that qualifies you to ask Medicare to recalculate your IRMAA surcharge based on a more recent tax year.
Loss of Coverage — Pérdida de Cobertura
Loss of coverage occurs when you involuntarily lose your health insurance—because you lost a job, aged off a parent's plan at 26, your COBRA expired, your employer stopped offering benefits, or your Medicaid or CHIP eligibility ended.
Managed Care Organization — Organización de Atención Médica Administrada
A Managed Care Organization (MCO) is a health plan or entity that coordinates and delivers medical services through a contracted provider network, using tools such as prior authorization, care management, utilization review, and referral requirements to control costs and improve quality.
Medicaid — Medicaid
Medicaid is a joint federal-state health insurance program that provides coverage to low-income individuals and families, including children, pregnant women, elderly adults, and people with disabilities.
Medicaid Expansion — Expansión de Medicaid
Medicaid Expansion refers to the ACA provision allowing states to extend Medicaid to most adults under 65 with incomes up to 138 percent of the Federal Poverty Level, regardless of disability or family structure.
Medicaid Expansion CHIP — Expansión de Medicaid CHIP
Medicaid Expansion CHIP refers to Children's Health Insurance Program coverage provided under Medicaid expansion rules in states that adopted the ACA expansion.
Medicaid Spend-Down — Spend-Down de Medicaid
Medicaid spend-down is a pathway to Medicaid eligibility for individuals whose income exceeds normal limits but who have high medical expenses.
Medical Necessity — Necesidad médica
Medical necessity is a standard insurers use to determine whether a service, treatment, or supply is appropriate and will be covered.
Medicare Advantage — Medicare Advantage
Medicare Advantage (Part C) is an alternative to Original Medicare offered by private insurance companies approved and regulated by Medicare.
Medicare Part A — Medicare Parte A
Medicare Part A is hospital insurance provided under the federal Medicare program.
Medicare Part B — Medicare Parte B
Medicare Part B covers outpatient medical services including doctor visits, preventive care, outpatient surgery, durable medical equipment, and certain laboratory tests.
Medicare Part C (Medicare Advantage) — Medicare Parte C (Medicare Advantage)
Medicare Part C, or Medicare Advantage, is an alternative to Original Medicare offered by private insurers approved by Medicare.
Medicare Part D — Medicare Parte D
Medicare Part D provides prescription drug coverage available as a standalone plan to complement Original Medicare or included in Medicare Advantage plans.
Medicare Secondary Payer — Medicare como Pagador Secundario
Medicare Secondary Payer (MSP) rules determine when Medicare pays after another insurer—such as an employer group health plan, workers' compensation, or auto insurance—pays first.
Medicare Supplement (Medigap) — Suplemento de Medicare (Medigap)
A Medicare Supplement plan, commonly called Medigap, is private health insurance designed to cover the cost-sharing gaps left by Original Medicare (Parts A and B).
Medigap — Medigap (Seguro Suplementario de Medicare)
Medigap, also called Medicare Supplement Insurance, is private insurance sold by insurance companies to help pay the gaps in Original Medicare—copays, coinsurance, and deductibles you would otherwise pay out of pocket.
Medigap Open Enrollment — Inscripción Abierta de Medigap
Medigap Open Enrollment is a one-time, six-month window that starts the month you turn 65 and are enrolled in Medicare Part B.
Network Adequacy — Suficiencia de la red
Network adequacy refers to federal and state standards requiring that a health insurance plan's provider network includes a sufficient number and variety of providers — including primary care, specialists, hospitals, and mental health professionals — close enough to where enrollees live and work.
Network Exception — Excepción de red
A network exception, sometimes called a network gap exception or out-of-network exception, is a formal approval from your insurance company allowing you to receive care from an out-of-network provider at in-network cost-sharing rates.
No Surprises Act — Ley de No Sorpresas
The No Surprises Act is a federal law effective January 1, 2022, that protects patients from unexpected medical bills.
Non-Covered Service — Servicio no cubierto
A non-covered service is a medical service, treatment, or supply that your health insurance plan will not pay for.
Non-Quantitative Treatment Limitation — Limitación de Tratamiento No Cuantitativa
A Non-Quantitative Treatment Limitation (NQTL) is a non-numeric restriction a health plan places on mental health or substance use disorder benefits—such as prior authorization requirements, step therapy protocols, network design decisions, reimbursement rates, or medical necessity criteria.
Notice of Action — Aviso de Acción
A Notice of Action (NOA) is a written document your Medicaid managed care plan or insurer must send when it takes an action affecting your benefits—such as denying a requested service, reducing your current coverage, or terminating your enrollment.
Observation Status — Estado de observación
Observation status is a billing classification used when a hospital keeps you for monitoring or treatment but has not formally admitted you as an inpatient.
Open Enrollment Period — Período de Inscripción Abierta
Open Enrollment is the annual period when individuals can enroll in, change, or drop health insurance coverage without a qualifying life event.
Original Medicare — Medicare Original
Original Medicare is the traditional federal health insurance program for people 65 and older and certain individuals with disabilities.
Out-of-Network Provider — Proveedor Fuera de Red
An out-of-network provider does not have a contract with your insurance plan.
Out-of-Pocket Maximum — Límite de Gastos de Bolsillo
The out-of-pocket maximum is the most you will have to pay for covered in-network services in a plan year.
Participating Provider — Proveedor participante
A participating provider is a doctor, hospital, or other healthcare provider that has signed a contract with an insurance company to accept the plan's negotiated rates as payment in full for covered services.
Plan Year — Año del Plan
A plan year is the 12-month period during which your health insurance benefits are active.
Postpartum Coverage — Cobertura Posparto
Postpartum coverage refers to health insurance benefits for the mother after childbirth.
PPO (Preferred Provider Organization) — Organización de Proveedores Preferidos
A PPO (Preferred Provider Organization) is an insurance plan offering more flexibility than an HMO.
Pre-Existing Condition — Condición Preexistente
A pre-existing condition is any health condition you had before your health insurance coverage began—such as diabetes, asthma, cancer, or heart disease.
Preexisting Condition — Condición preexistente
A preexisting condition is a health problem, illness, or injury you had before the start date of your current health insurance coverage — such as diabetes, cancer, asthma, or heart disease.
Premium — Prima
A premium is the monthly amount you pay to maintain your health insurance coverage, regardless of whether you use medical services that month.
Presumptive Eligibility — Elegibilidad Presuntiva
Presumptive eligibility allows authorized entities—such as hospitals, community health centers, or schools—to grant temporary Medicaid coverage to individuals who appear likely to qualify while the formal state application is being processed.
Primary Payer — Pagador Primario
When you have more than one health insurance plan, the primary payer is the insurance company that processes and pays your medical claim first.
Prior Authorization Denial — Denegación de autorización previa
A prior authorization denial occurs when your insurance company refuses to approve coverage for a requested service, treatment, or medication before it is provided.
Procedure Code — Código de procedimiento
A procedure code identifies a medical service, treatment, or supply on an insurance claim.
Prospective Review — Revisión prospectiva
Prospective review is a type of utilization review performed before a planned medical service or treatment takes place.
Provider Network — Red de Proveedores
A provider network is the set of doctors, hospitals, pharmacies, and other healthcare facilities that have contracted with an insurance plan to provide services at negotiated rates.
Qualifying Health Plan — Plan de salud calificado
A qualifying health plan (QHP) is a health insurance plan that meets minimum standards established by the Affordable Care Act and is certified to be sold on the Health Insurance Marketplace.
Qualifying Life Event — Evento de Vida Calificador
A qualifying life event is a change in circumstances that makes a person eligible for a Special Enrollment Period outside of open enrollment.
Qualifying Life Event — Evento de Vida Calificado
A qualifying life event (QLE) is a change in your personal circumstances that makes you eligible to enroll in or change a health insurance plan outside of the annual Open Enrollment Period, triggering a Special Enrollment Period.
Quantitative Treatment Limitation — Limitación de Tratamiento Cuantitativa
A quantitative treatment limitation (QTL) is a numeric cap on health insurance benefits—such as a limit of 20 covered therapy sessions per year or a cap on inpatient mental health days.
Redetermination — Redeterminación
Redetermination is the periodic process—usually annual—by which Medicaid reviews your eligibility to confirm you still qualify for coverage.
Remittance Advice — Aviso de pago
A remittance advice (RA) is a document sent from an insurance payer to a healthcare provider that explains how a claim was processed and paid.
Retroactive Coverage — Cobertura Retroactiva
Retroactive coverage means your health insurance starts on a date before your enrollment was formally approved.
Retrospective Review — Revisión retrospectiva
Retrospective review is a type of utilization review conducted by an insurer after a medical service has already been provided.
Secondary Insurance — Seguro secundario
Secondary insurance is a health insurance plan that pays after your primary insurance has processed a claim.
Separate CHIP — CHIP Separado
Separate CHIP refers to a state Children's Health Insurance Program that operates independently from Medicaid, with its own eligibility rules, benefit packages, and cost-sharing requirements.
SLCSP — SLCSP (Plan de Plata de Menor Costo)
The Second Lowest Cost Silver Plan (SLCSP) is the marketplace benchmark plan used to calculate the maximum premium tax credit you are eligible to receive.
Special Enrollment Period — Período de Inscripción Especial
A Special Enrollment Period (SEP) is a window outside of the annual open enrollment period during which individuals can enroll in or change health insurance due to a qualifying life event.
Special Enrollment Period — Período de Inscripción Especial
A Special Enrollment Period (SEP) is a limited window—typically 60 days—outside the annual Open Enrollment Period during which you can enroll in or change a marketplace health insurance plan.
Step Therapy — Terapia escalonada
Step therapy, also called fail-first protocol, is an insurance cost-control practice requiring patients to try less expensive or generic medications or treatments before the insurer will cover a more costly or brand-name option.
Summary of Benefits — Resumen de Beneficios
A summary of benefits is a brief overview document explaining what a health insurance plan covers, what you pay in premiums, deductibles, copays, and coinsurance, and which services are included or excluded.
Summary of Benefits and Coverage — Resumen de beneficios y cobertura
The Summary of Benefits and Coverage (SBC) is a standardized, plain-language document that health insurers must provide to help you compare plans.
Summary of Benefits and Coverage — Resumen de Beneficios y Cobertura
The Summary of Benefits and Coverage (SBC) is a standardized, plain-language document the ACA requires all health insurers to provide when you apply for, enroll in, or renew a health plan.
Superbill — Superfactura
A superbill is a detailed itemized receipt provided by a healthcare provider — most commonly therapists, out-of-network doctors, and chiropractors — that includes all the information your insurance company needs to process a reimbursement claim: patient and provider information, dates of service, diagnosis codes (ICD-10), procedure codes (CPT or HCPCS), and charges.
Surprise Billing — Facturación sorpresa
Surprise billing occurs when you unknowingly receive care from an out-of-network provider — often in an emergency or when an out-of-network specialist is used at an in-network facility without your knowledge — and then receive an unexpectedly large bill.
Tertiary Insurance — Seguro terciario
Tertiary insurance is a third health insurance plan that pays after both the primary and secondary insurers have processed a claim.
Uninsured — Sin Seguro
An uninsured person is someone who has no health insurance coverage—not through an employer, government program such as Medicaid or Medicare, or an individual marketplace plan.
Upcoding — Sobrecodificación
Upcoding is fraudulent or abusive billing practice in which a healthcare provider submits a billing code for a more complex, higher-cost service than was actually performed.
Urgent Prior Authorization — Autorización Previa Urgente
Urgent prior authorization—also called expedited prior authorization—is an accelerated insurance review for requests where waiting for a standard review could seriously jeopardize the patient's health or safety.
Utilization Review — Revisión de utilización
Utilization review (UR) is the process insurers use to evaluate whether the medical care you receive — or plan to receive — is medically necessary, appropriate, and efficient.
Value-Based Care — Atención basada en valor
Value-based care is a healthcare payment and delivery model that rewards providers for achieving better patient health outcomes rather than simply for the volume of services they deliver.
Waiting Period — Período de Espera
A waiting period is the time between when you enroll in a health insurance plan and when your coverage becomes active, or the time before a specific benefit begins.

Costs and financial help (24)

Credit Bureau — Agencia de Crédito
A credit bureau—also called a credit reporting agency—is a company that collects, maintains, and sells financial information about individuals.
Credit Report — Informe de Crédito
A credit report is a detailed record of your borrowing history and financial behavior, compiled by credit bureaus such as Equifax, Experian, and TransUnion.
Debt Collector — Cobrador de Deudas
A debt collector is a company or individual hired to recover unpaid debts, including medical bills, on behalf of the original creditor or after purchasing the debt at a discount.
Debt Validation — Validación de Deuda
Debt validation is your legal right under the Fair Debt Collection Practices Act (FDCPA) to request written proof that a debt is accurate and that the collection agency has the legal authority to collect it from you.
Deferred Interest — Interés Diferido
Deferred interest is a financing arrangement commonly offered by medical credit cards—such as CareCredit—and hospital payment plan programs.
Estate — Patrimonio
In healthcare and benefits contexts, an estate refers to all the property, assets, and outstanding debts a person leaves behind at death.
Estate Recovery — Recuperación de Patrimonio
Estate recovery is a federal requirement that state Medicaid programs seek reimbursement from a deceased beneficiary's estate for costs of certain services.
Extra Help — Ayuda Extra
Extra Help, also called the Low Income Subsidy (LIS), is a Social Security Administration program that helps Medicare beneficiaries with limited income and resources pay for Medicare Part D prescription drug costs.
Federal Poverty Level — Nivel de Pobreza Federal
The federal poverty level (FPL) is an income measure published annually by the U.S.
Financial Assistance Policy — Política de Asistencia Financiera
A financial assistance policy (FAP), sometimes called a charity care policy, is a written document that nonprofit hospitals are required to maintain under IRS Section 501(r) to keep their tax-exempt status.
Form 1095-A — Formulario 1095-A
Form 1095-A is the Health Insurance Marketplace Statement sent each January by your federal or state Marketplace if you were enrolled in a Marketplace plan during the previous year.
Form 8962 — Formulario 8962
Form 8962 is the IRS tax form used to calculate and reconcile the Premium Tax Credit (PTC) for people who enrolled in an ACA Marketplace health plan.
Form SSA-44 — Formulario SSA-44
Form SSA-44 is a Social Security Administration document you complete to ask Medicare to lower your Income-Related Monthly Adjustment Amount (IRMAA) because of a life-changing event—such as retirement, divorce, or the death of a spouse—that significantly reduced your income since the tax year Medicare used to set your current premium.
Health Savings Account — Cuenta de Ahorros para la Salud
A Health Savings Account (HSA) is a tax-advantaged bank account available to people enrolled in a qualifying High-Deductible Health Plan (HDHP).
HRA — Acuerdo de Reembolso de Salud
A Health Reimbursement Arrangement (HRA) is an employer-funded account that reimburses you tax-free for qualified out-of-pocket medical expenses and, in some plan designs, individual insurance premiums.
IRS Publication 502 — Publicación del IRS 502
IRS Publication 502, Medical and Dental Expenses, is a free IRS guide explaining which healthcare costs you may deduct on Schedule A of your federal income tax return.
Lien — Gravamen
In healthcare, a lien is a legal claim placed against your personal injury settlement, lawsuit proceeds, or estate to recover medical costs paid on your behalf.
LPFSA — LPFSA (FSA de Propósito Limitado)
A Limited Purpose Flexible Spending Account (LPFSA) is a pre-tax spending account restricted to qualified dental and vision expenses only, designed to be used alongside a Health Savings Account (HSA).
MAGI — MAGI (Ingreso Bruto Ajustado Modificado)
MAGI—Modified Adjusted Gross Income—is the income measure used by the federal government to determine eligibility for ACA marketplace subsidies, Medicaid, and CHIP.
Modified Adjusted Gross Income — Ingreso Bruto Ajustado Modificado
Modified Adjusted Gross Income (MAGI) is the income figure the federal government uses to determine eligibility for ACA marketplace subsidies, Medicaid, and CHIP.
Probate — Sucesión
Probate is the court-supervised legal process for settling a deceased person's estate.
Qualified Medical Expense — Gasto Médico Calificado
A qualified medical expense is a healthcare cost defined by the IRS under Section 213(d) that can be paid tax-free from a Health Savings Account (HSA), Flexible Spending Account (FSA), or Health Reimbursement Arrangement (HRA).
Reconciliation — Conciliación
In the ACA context, reconciliation is the process of settling the difference between the advance premium tax credits (APTC) you received during the year and the amount you were actually entitled to based on your final income.
Undue Hardship Waiver — Exención por Dificultad Excesiva
An undue hardship waiver is an exemption from a financial or legal obligation granted when complying would impose an unreasonable burden.

Billing (19)

Adjustment — Ajuste
An adjustment is a change made to the original amount billed on a medical claim.
Air Ambulance — Ambulancia Aérea
An air ambulance is emergency medical transport by helicopter or fixed-wing aircraft, typically used when ground transport is too slow or impractical due to distance or terrain.
Amounts Generally Billed — Montos Generalmente Cobrados
Amounts Generally Billed (AGB) is the maximum amount a nonprofit hospital may charge a patient who does not have insurance, under IRS Section 501(r) rules.
Chargemaster — Lista de Precios del Hospital
A chargemaster—also called a charge description master (CDM)—is a hospital's internal list of standard prices for every service, procedure, drug, supply, and room charge it provides.
Collections — Cobros
Collections refers to the process of pursuing payment on an unpaid medical bill after standard billing has failed.
Cost-Based Fee — Tarifa Basada en Costos
A cost-based fee is a payment method used by Medicare and Medicaid to reimburse certain federally qualified health centers (FQHCs) and rural health clinics (RHCs).
CPT Code — Código CPT
A Current Procedural Terminology (CPT) code is a standardized five-digit numeric code maintained by the American Medical Association that describes a specific medical service, diagnostic procedure, or surgical operation.
Date of Service — Fecha de Servicio
The date of service (DOS) is the specific calendar date on which a medical service, procedure, exam, or prescription was provided to a patient.
Denial Code — Código de Denegación
A denial code is a standardized alphanumeric code that appears on an Explanation of Benefits (EOB), remittance advice, or claim rejection notice to indicate why an insurance claim was denied, reduced, or adjusted.
Extraordinary Collection Action — Acción de Cobro Extraordinaria
An extraordinary collection action (ECA) is an aggressive debt collection measure that nonprofit hospitals subject to IRS Section 501(r) are prohibited from taking before making a reasonable effort to determine if a patient qualifies for financial assistance.
Good Faith Estimate — Estimado de Buena Fe
A Good Faith Estimate (GFE) is a written cost estimate that healthcare providers are required to give uninsured or self-pay patients before a scheduled service costing at least $400.
Ground Ambulance — Ambulancia Terrestre
A ground ambulance is a land vehicle staffed by emergency medical technicians or paramedics that transports patients to a hospital during a medical emergency.
Independent Dispute Resolution — Resolución Independiente de Disputas
Independent Dispute Resolution (IDR) is a federal arbitration process created by the No Surprises Act where an out-of-network provider and a health insurer submit their payment disagreement to a neutral third-party arbitrator when they cannot agree on reimbursement.
Notice of Observation Treatment — Aviso de Tratamiento en Observación
A Notice of Observation Treatment—also called the Medicare Outpatient Observation Notice (MOON)—is a required written notice hospitals must give Medicare and Medicaid beneficiaries receiving hospital services under observation status rather than formal inpatient admission.
Payment Plan — Plan de Pago
A payment plan is a formal agreement between you and a hospital, clinic, or provider to repay a medical bill in smaller, scheduled installments over time rather than a single lump sum.
Remark Code — Código de Observación
A remark code is an alphanumeric code that appears on an Explanation of Benefits or remittance advice to provide additional information about how a claim was processed.
Self-Pay — Pago Propio
Self-pay refers to a patient who does not have health insurance or who chooses to pay for a medical service out of pocket rather than through insurance.
Timely Filing — Presentación Oportuna
Timely filing is the deadline set by a health insurance plan within which a claim must be submitted after the date of service.
Two-Midnight Rule — Regla de las Dos Medianoche
The two-midnight rule is a Medicare billing policy stating that when a hospital physician expects a patient to need care spanning at least two midnights, the stay is presumed an appropriate inpatient admission billable under Part A.

Administration (18)

CDC (Centers for Disease Control and Prevention) — CDC (Centros para el Control y la Prevención de Enfermedades)
The Centers for Disease Control and Prevention (CDC) is the leading federal public health agency in the United States, operating under HHS.
Charity Care — Atención de Caridad
Charity care is free or reduced-cost medical care provided by hospitals to patients who cannot afford to pay.
CMS (Centers for Medicare & Medicaid Services) — CMS (Centros de Servicios de Medicare y Medicaid)
The Centers for Medicare & Medicaid Services (CMS) is the federal agency within HHS responsible for administering Medicare, Medicaid, CHIP, and the ACA Marketplace.
Explanation of Benefits (EOB) — Explicación de Beneficios
An Explanation of Benefits (EOB) is a document sent by your insurer after a medical claim is processed.
HIPAA (Health Insurance Portability and Accountability Act) — HIPAA (Ley de Portabilidad y Responsabilidad del Seguro Médico)
HIPAA (Health Insurance Portability and Accountability Act) is a federal law enacted in 1996 that establishes national standards for the protection of health information.
Hospital Financial Assistance — Asistencia Financiera Hospitalaria
Hospital financial assistance programs, also called charity care programs, provide free or discounted care to patients who cannot pay their medical bills.
HRSA (Health Resources and Services Administration) — HRSA (Administración de Recursos y Servicios de Salud)
The Health Resources and Services Administration (HRSA) is the primary federal agency for improving healthcare access to people who are uninsured, isolated, or medically vulnerable.
Informed Consent — Consentimiento Informado
Informed consent is the process by which a healthcare provider explains a proposed treatment, procedure, or research participation to a patient, including its purpose, risks, benefits, and alternatives, so the patient can make a voluntary and educated decision.
IRB (Institutional Review Board) — Junta de Revisión Institucional
An Institutional Review Board (IRB) is an independent committee that reviews and approves research involving human subjects to ensure participant rights, safety, and welfare are protected.
Itemized Medical Bill — Factura Médica Detallada
An itemized medical bill lists every charge for a healthcare encounter individually — each procedure, medication, supply, and service with its corresponding billing code (CPT or HCPCS code) and charge amount.
Medical Debt — Deuda Médica
Medical debt is unpaid healthcare bills that a patient owes to a hospital, clinic, or provider.
Medical Interpreter Services — Servicios de Interpretación Médica
Medical interpreter services provide qualified language interpretation for patients with limited English proficiency during healthcare encounters.
Prior Auth (Authorization) — Autorización Previa
Prior auth is the shortened term for prior authorization, the insurer approval required before receiving certain medical services or medications.
Prior Authorization — Autorización Previa
Prior authorization (PA) is approval from your insurance company required before you receive certain medical services, medications, or procedures.
Referral — Derivación
A referral is a formal recommendation or authorization from your primary care provider (PCP) to see a specialist or receive a specific service.
Section 1557 — Language Access Rights — Sección 1557 — Derechos de Acceso al Idioma
Section 1557 of the Affordable Care Act prohibits discrimination in healthcare on the basis of race, color, national origin, sex, age, or disability in programs receiving federal funding.
Sliding Fee Scale — Escala de Tarifas Móviles
A sliding fee scale is a payment structure that adjusts the cost of healthcare services based on the patient's income and family size.
Surprise Bill — Factura Sorpresa
A surprise bill is an unexpected medical charge a patient receives when they receive care from an out-of-network provider without knowing it — for example, when an out-of-network anesthesiologist assists during an in-network surgery, or when a patient is taken to an out-of-network ER during an emergency.

Other areas of the glossary

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This page is a language reference. It is not medical advice. Last reviewed: October 7, 2026