Decoding Health Care Acronyms Part I
Are we both speaking English? Conversing with health insurance professionals can feel like you’re communicating in a foreign language. Keeping track of all the acronyms you need to know about your health coverage can be difficult! Understanding these acronyms can help provide you with a knowledge base to navigate your benefits. We’re translating the most commonly used ones in the insurance industry so you can finally start feeling fluent. Start below for Part I, and stay tuned for future installments for decoding more healthcare acronyms!
PCP = Primary Care Physician
A primary care physician is needed when enrolling in an HMO medical plan. Your primary care physician will be your first line of defense for your healthcare needs to include well visits, sick visits and referrals. Finding a primary care physician that you feel comfortable with and can help facilitate your needs can be difficult, however it’s the key to keeping you healthy.
SPEC= Specialist
Physicians that specialize in one area of medicine are considered a specialist. When seeking care from a specialist, your insurance may require you to obtain a referral from your primary care physician before seeking care. If a referral is not obtained prior to your visit, your visit could be denied. If your plan is open access, you can bypass your primary and go directly to a specialist that participates in your network. Examples of specialists are: ENT, Allergist, Gastroenterologist and Cardiologist. Insurance carriers usually have a separate charge designated for specialist vs care in a primary care physician setting.
PHI = Authorization Form for Information Release
In order to protect the safety of the member and be in HIPAA compliance an insurance carrier will not release personal healthcare information to include claims without an Authorization Form on file. The form will allow you to release information to not only yourself but also your benefits representative. You can determine how much or how little information you would like to release. You also have the ability to indicate a date in which the form will expire. Processing time can vary, however once complete the insurance carrier will discuss your questions and concerns.
DOS= Date of Service
The date of service is the day in which you had your healthcare services performed. For example, it could be the date you had a doctor’s appointment or the date you had lab work performed. This date is important to know when you are reviewing your claims or invoices in order to make sure the date listed coincides with the date you had the service rendered.
EOB = Explanation of Benefits
When a claim is processed at the insurance carrier an Explanation of Benefits is generated. This document is then either mailed or emailed to the member and can also be accessed on your individual insurance carrier portal. Your Explanation of Benefits will relay key information pertaining to your claim. It will breakdown the service charges, to include what the insurance carrier is going to cover, what you owe and the allowed amounts. You can review what was applied towards your deductible, copays, and coinsurance and also see how much you’ve met year to date towards your deductible and annual out of pocket maximum. If a claim is denied, has limitations or other restrictions, a code will show with a key describing why this occurred. In this situation, usually you will need additional assistance or guidance and can contact your insurance provider for assistance.
SBC = Summary of Benefits and Coverage
Under the Affordable Care Act, a Summary of Benefits and Coverage must be provided to employees that are newly eligible to enroll in the health benefits or during the groups open enrollment period. The purpose of the document is to provide standard benefit information to assist with electing your benefits. The document includes the overview of benefits, member responsibilities, cost sharing, limitations, and exclusions. Your employer may send you the document electronically or provide a paper copy. If the document is not provided to you in a timely manner, penalties may apply to the employer.
While these terms are common knowledge in the insurance industry, we understand that they can sound like gibberish to our clients At Corporate Coverage, we stay away from jargon like this and do our best to speak to you in common English. But we can’t promise that you’ll never come across other insurance professionals who sneak in some of these terms. Which is why we recommend keeping this cheat sheet handy – you never know when you’ll need it!
Found these helpful? Stick around for Part II for even more health care acronyms, decoded.