120 terms

Glossary

The words in a denial letter, in plain language, with the official wording beside them.

A

Administrative Law Judge (ALJ): A judge who hears your Medicare appeal at the third level, after an outside contractor has already said no. Your claim has to be worth at least a set dollar amount to get this hearing.; Official wording: Administrative Law Judge at the Office of Medicare Hearings and Appeals (ALJ); Example: After a Qualified Independent Contractor upholds your denial, you can ask for a hearing with an Administrative Law Judge if at least $200 is still in dispute (the 2026 amount).
Advance Beneficiary Notice of Noncoverage (ABN): A form that a doctor or supplier gives you before a service when they expect Original Medicare not to pay. It warns you that you may have to pay the bill yourself.; Official wording: Advance Beneficiary Notice of Noncoverage (form CMS-R-131); Example: Before a medical supply order, the supplier hands you this form because Medicare may not pay, so you know you could be billed.
Adverse benefit determination: The official name for a denial. It means your plan said no, paid less than you expected, stopped coverage you had, or cancelled your coverage. Your plan has to tell you in writing and explain how to appeal.; Official wording: A denial, reduction or termination of a benefit, or a failure to pay in whole or in part, including a rescission of coverage; Example: Your letter says 'adverse benefit determination' because your plan refused to pay for a knee scan.
Aid paid pending: In Medicaid, a rule that can keep your services going while your hearing is decided, if you ask for the hearing before the change takes effect. If you lose, the state may ask you to pay back what it spent on those services.; Official wording: Continuation of benefits pending a fair hearing; Example: Your Medicaid home care hours are being cut on a date shown on your notice. You ask for a hearing before that date, so the hours stay the same until the decision, unless the only issue is a change in law or policy.
Allowed amount: The price your plan treats as the cost of a service. Your share of the cost is worked out from this number, not from the amount the provider charged.; Example: A provider charges $500 (example amount), but your plan's allowed amount is $300 (example amount), so your plan works out what you owe from the $300.
Amount in controversy: The dollar value of what you are fighting over in a Medicare appeal. At some levels, Medicare will only hear your case if the amount is high enough.; Official wording: Amount remaining in controversy; Example: For 2026, a Medicare Administrative Law Judge hearing needs at least $200 in dispute and federal court review needs at least $1,960. Claims can sometimes be added together to reach the amount.
Appeal: A request that your plan or program look at its decision again. Your first appeal usually goes to the plan that made the decision.; Example: Your plan denied a scan, so you write to the plan and ask it to review that decision.
Authorized representative: Someone you pick to act for you in a claim or appeal, such as a family member, friend, advocate, lawyer or doctor. A job-based plan has to let you use one. In an urgent case, a health care professional who knows your condition must be allowed to act for you.; Official wording: Authorized representative (in Medicare, the Appointment of Representative form CMS-1696); Example: You sign a form so your daughter can call your plan and file an appeal for you.

B

Balance billing: When a provider who is not in your plan's network bills you for the gap between what they charged and what your plan paid. The No Surprises Act stops this for emergency care, some care from out-of-network clinicians at in-network hospitals, and air ambulances. It does not cover ground ambulances.; Example: After an emergency visit, the hospital may charge you only your in-network share, not the gap between its price and your plan's payment.

C

Centers for Medicare & Medicaid Services (CMS): The federal agency that runs Medicare and works with states on Medicaid and the Children's Health Insurance Program. It is part of the United States Department of Health and Human Services.; Official wording: Centers for Medicare & Medicaid Services; Example: The list of which states run their own independent review process is published by this agency.
Children's Health Insurance Program (CHIP): A government health insurance program for children, run by each state with federal rules. Some states run it as part of Medicaid and some run a separate program with its own appeal steps.; Official wording: Children's Health Insurance Program; Example: In a state with a separate CHIP program, a denied service goes to an independent external review instead of a Medicaid fair hearing.
Claim: A request for your plan to pay for care, or to approve care before you get it. A request for approval ahead of time is also a claim.; Example: Your clinic sends a claim for your blood tests, and your plan sends back a decision.
Claim file: Everything your plan used or looked at to decide your claim, such as its notes, the reviewer's reasons, your records and the rules it applied. You can ask for a copy for free.; Official wording: All documents, records and other information relevant to the claim; Example: After a denial, you write to ask for your claim file and find the reviewer's notes inside it.
Claimant: The person who makes a claim or an appeal. That is you, or someone acting for you.; Official wording: Claimant; Example: A plan's rules say it must give the claimant a decision within a set number of days.
Clinical appeal (Veterans Affairs): At the Department of Veterans Affairs, the way to challenge a medical treatment decision by your Veterans Affairs care team, such as whether a medicine should be prescribed. It starts with a written appeal to the patient advocate at your Veterans Affairs medical facility.; Official wording: Veterans Health Administration clinical appeal; Example: Your Veterans Affairs doctor will not prescribe a therapy you want, so you send a written clinical appeal to the patient advocate at your Veterans Affairs medical center.
Coinsurance: Your share of a bill, as a percentage of the allowed amount, for a covered service.; Example: With 20% coinsurance on a $300 allowed amount (example amounts), you pay $60 and your plan pays the rest.
Concurrent care (ongoing treatment): Treatment your plan already approved that you are still getting. If the plan cuts it short or ends it, that counts as a denial, and the plan has to give you notice early enough to appeal before the care stops.; Official wording: Concurrent care decision; Example: Your plan approved a set number of therapy visits (example), then says the next visit is your last. That is a denial you can appeal.
Consumer Assistance Program (CAP): A state program that helps people with private health insurance understand their rights. It can file an appeal for you. A denial notice from a plan that is not grandfathered should list the contact details for your state's program.; Official wording: Consumer Assistance Program; Example: You call your state's Consumer Assistance Program, and a caseworker explains the steps of your appeal.
Coordination of benefits: The rules that decide which plan pays first when you have more than one health plan, such as your own and your spouse's.; Example: A claim is denied because your plan thinks your spouse's plan should pay first, so you send your plan the details of your other coverage.
Copay: A flat dollar amount you pay for a service, set by your plan.; Official wording: Copayment; Example: Your plan charges a $30 copay (example amount) for a doctor visit.

D

De novo review: A fresh look at a case, as if no one had decided it before. The reviewer does not have to go along with the earlier decision.; Official wording: De novo review; Example: An independent review organization reviews your claim from the start, so it is not bound by what your plan decided.
Decision review (Veterans Affairs): At the Department of Veterans Affairs, the way to challenge a health care benefit decision, such as eligibility or payment of a community care claim. The options are a Higher-Level Review, a Supplemental Claim or an appeal to the Board of Veterans' Appeals. In general you have one year from the date on the decision notice, and the date on your notice controls.; Official wording: Decision review process (Veterans Appeals Improvement and Modernization Act of 2017); Example: Veterans Affairs refuses to pay your emergency care claim, so you ask for a Higher-Level Review within one year of the date on the decision notice.
Deductible: The amount you pay yourself for covered care before your plan starts paying its share of some services.; Example: With a $1,000 deductible (example amount), you pay the first $1,000 of covered costs that the deductible applies to before the plan starts to pay its share.
Deemed exhaustion: If your plan does not follow the appeal rules, you are treated as having finished its appeal steps and can move on to the next step, such as independent review or court. A small mistake that does no harm does not count.; Official wording: Deemed exhaustion of internal claims and appeals; Example: Your plan never answers your appeal in time, so you may be able to ask for external review without waiting any longer.
Denial: When a plan or program says it will not pay for or approve something, or will pay less than you expected. The official term in the rules is adverse benefit determination.; Official wording: Adverse benefit determination; Example: Your plan sends a letter saying it will not cover a scan your doctor ordered.
Denial code: A short code on your notice that names the reason for the denial. A plan that is not grandfathered must also give you the denial code and tell you what it means.; Example: Your notice shows a code, and the plan's explanation next to it says the claim was denied because you did not get approval first.
Department of Labor Employee Benefits Security Administration (EBSA): The federal agency that oversees job-based health plans. If your employer's plan broke the rules, you can ask it for help at 1-866-444-3272.; Official wording: Employee Benefits Security Administration, part of the United States Department of Labor; Example: Your employer plan will not send you documents you asked for in writing, so you call the Employee Benefits Security Administration's benefits advisors.
Diagnosis code and treatment code: Numbers on a claim that stand for your condition and for the service you got. After a denial, a plan that is not grandfathered must give you these codes and their meanings if you ask. Asking for them is not an appeal.; Example: You ask your plan for the codes on your denied claim so you can check that they match what your doctor treated.

E

Early and Periodic Screening, Diagnostic and Treatment (EPSDT): A Medicaid rule for people under 21. The state has to cover medically necessary care that federal Medicaid law allows, whether or not the state's own plan lists the service. The state decides what is medically necessary case by case.; Official wording: Early and Periodic Screening, Diagnostic and Treatment; Example: Medicaid denies therapy for a 12-year-old because it is 'not a covered benefit'. Because of this rule, the family can challenge that denial, and the state decides medical necessity case by case.
Emergency medical condition: A problem where, going by your symptoms, an ordinary person with average health knowledge would reasonably expect that waiting for care could seriously harm your health. This includes mental health and substance use conditions.; Official wording: Emergency medical condition (prudent layperson standard); Example: Severe chest pain sends you to the emergency room. Your plan judges the visit by your symptoms, not only by the final diagnosis.
Employee Retirement Income Security Act (ERISA): A federal law that sets rules for most job-based plans from private employers. It affects who regulates your plan and what you can do in court if your appeals fail.; Official wording: Employee Retirement Income Security Act of 1974 (ERISA); Example: If your employer's plan is self-funded under this law, you complain to the federal Employee Benefits Security Administration, not the state insurance department.
Exception (Medicare Part D): A request that your Medicare drug plan cover a drug that is not on its list (a formulary exception), or charge you the price of a lower tier (a tiering exception). Your prescriber has to give a supporting statement.; Official wording: Formulary exception; tiering exception; Example: Your drug plan does not list the medicine your doctor prescribed, so your doctor sends a statement explaining why you need it and asks for an exception.
Exclusion: Something your plan's contract says it does not cover. A denial notice must name the specific plan provision it relied on, so you can read that exact wording.; Example: Your notice says a service is excluded, so you ask for the plan wording the denial relied on.
Expedited appeal: A fast appeal for urgent situations, when waiting the normal time could seriously harm your health. For a job-based plan, an urgent appeal is decided as soon as possible and within 72 hours. Check the date and timing on your notice, which controls.; Official wording: Expedited (urgent) review; Example: Your doctor says a delay in your cancer treatment could harm you, so you ask your plan for an expedited appeal.
Experimental or investigational: A plan's label for a treatment it says is not yet proven. A denial for this reason involves medical judgment, so an independent reviewer can look at it.; Example: Your plan says a new therapy is investigational and denies it. You can ask for independent review of that denial.
Explanation of Benefits (EOB): A statement from your plan showing what a provider billed, what the plan paid and what you may owe. It is not a bill. It often shows why a claim was denied.; Official wording: Explanation of Benefits; Example: Your EOB shows a $0 payment (example amount) and a reason code, so you look up the reason before you pay the provider.
External review: A review of a denial by independent doctors who do not work for your plan. It is also called independent review. For most plans it comes after the plan's own appeal. If the reviewers decide for you, your plan has to follow the decision.; Official wording: External review (independent review); Example: After your plan upholds its denial, you ask for external review within the time on your notice. For most plans that is at least four months, and your notice controls.

F

Fair hearing: In Medicaid, a hearing before a state official where you explain why a denial or cut is wrong. You have the right to ask for one and to be represented.; Official wording: State fair hearing; Example: Your Medicaid plan upholds its denial of a service, and you ask the state for a fair hearing.
Federal Employees Health Benefits (FEHB) program: The health insurance program for federal employees and retirees. Its plans have their own appeal steps: first the insurance company, then the Office of Personnel Management.; Official wording: Federal Employees Health Benefits program; Example: You ask your plan in writing to reconsider within 6 months of the date of its denial notice. If it says no, you can ask the Office of Personnel Management to review. Your notice controls.
Federal external review process: The independent review used by self-funded employer plans, and by insurers in states whose own process does not meet federal standards. It runs through independent review organizations, or through a version run by the federal government. Under the federal process you are not charged. The government-run version has an information line at 1-888-866-6205.; Official wording: HHS-administered Federal External Review Process; Example: Your self-funded employer plan upholds its denial, so your external review goes through the federal process instead of the state's.
Fee-for-service: A way a program pays: it pays providers directly for each service, instead of paying a private company to manage your care.; Example: Medicaid in a fee-for-service state decides your claim itself, and its notice tells you how to ask for a fair hearing.
Formulary: A plan's list of drugs it covers. Drugs are often sorted into tiers that cost different amounts.; Example: Your doctor prescribes a drug that is not on the plan's formulary, so you can ask for an exception.
Full and fair review: Your right during an appeal to send comments and documents and have everything you send considered. The person who decides cannot be the person who made the first decision or work for that person. If the denial rests on a medical judgment, the reviewer has to consult a health professional with the right training.; Official wording: Full and fair review; Example: You send new records with your appeal, and the reviewer has to consider them even though the first reviewer never saw them.
Fully insured plan: A plan where an employer buys a policy from an insurance company, and the insurer pays the claims. State insurance law applies to the insurer.; Official wording: Fully insured (health insurance coverage); Example: If your job-based plan is fully insured, your state insurance department can take your complaint about the insurer.

G

Good cause (late appeal): A good reason for filing late, such as serious illness, a death or serious illness in the family, records destroyed in a fire, or wrong information from the contractor. Medicare may accept a late appeal for good cause.; Official wording: Good cause for late filing; Example: You were in the hospital when your deadline passed, so you explain that in your late Medicare appeal.
Good faith estimate: A written estimate of what a provider expects to charge. Patients who are uninsured, or who choose not to use insurance, must be given one. The rule for insured patients has not been put into effect.; Official wording: Good faith estimate; Example: A clinic gives an uninsured patient an estimate of $1,200 (example amount). If the provider later bills $1,600 (example amount), the patient may qualify to dispute the bill.
Grandfathered plan: A health plan that was in place on 23 March 2010 and has not made disqualifying changes. It is exempt from some Affordable Care Act protections, including the general rule on external review. An employer plan of this kind still has to follow the older federal claims rules.; Official wording: Grandfathered health plan; Example: Your plan's booklet says it believes it is grandfathered, so some extra Affordable Care Act rights may not apply, but the basic claim and appeal rules still do.
Grievance: A complaint about something other than a coverage decision, such as rude service or long waits. It is different from an appeal.; Example: You complain to your plan about a long wait on the phone. That is a grievance, not an appeal of a denial.

H

Health care sharing ministry: A group whose members agree to share one another's medical costs based on shared beliefs. The federal tax law does not treat it as insurance, and the federal appeal and No Surprises Act rules do not apply to it.; Official wording: Health care sharing ministry; Example: A sharing ministry declines to share a bill. No federal appeal rule was found for sharing ministries, so check the ministry's own rules.
Health Insurance Marketplace: The government website and system where people buy individual health plans. HealthCare.gov is the federal one, and some states run their own. The Marketplace decides your eligibility and tax credits. Your insurance company decides your claims.; Official wording: Health Insurance Marketplace (also called the exchange); Example: If the Marketplace says you do not qualify for a tax credit, you file a Marketplace appeal. If your insurer denies a claim, you appeal to the insurer.
Health Insurance Portability and Accountability Act (HIPAA) right of access: Your right to get your own records from a health plan or provider. For a plan, these include claims and case management records. Only a reasonable, cost-based copying fee is allowed.; Official wording: Health Insurance Portability and Accountability Act of 1996 (HIPAA), right of access; Example: You ask your plan in writing for your claims records. It has 30 days to act, and it may take one extension of up to 30 more days if it explains the delay in writing.

I

Important Message from Medicare: A paper notice a hospital has to give you when you are admitted and again before you leave. It explains your right to ask for a fast review if you think you are being sent home too soon.; Official wording: Important Message from Medicare (form CMS-10065); Example: You get the notice, believe discharge is too early, and call the Quality Improvement Organization no later than the day you are due to leave.
Improvement standard (Jimmo settlement): A myth that Medicare stops paying for skilled nursing or therapy once you stop getting better. Medicare covers skilled care that you need to keep your condition from getting worse.; Official wording: Jimmo v. Sebelius settlement (approved 24 January 2013); Example: A denial says you are 'not improving'. You can point out that skilled care needed to maintain your condition or slow decline can be covered.
In-network: Doctors, hospitals and other providers that have an agreement with your plan. You usually pay less when you use them.; Example: Your plan's directory lists a clinic as in-network, so you expect to pay only your normal share.
Independent dispute resolution: A process under the No Surprises Act where a plan and an out-of-network provider settle how much the provider is paid. You are not part of it, and you owe only your in-network share.; Official wording: Federal independent dispute resolution process; Example: A plan and an out-of-network anesthesiologist disagree about payment. They go through this process, and you still owe only your in-network share.
Independent Medical Review (IMR): California's name for external review of a health plan denial, run through the state's Department of Managed Health Care.; Official wording: Independent Medical Review, California Department of Managed Health Care; Example: A California health plan member whose denial was upheld files for an Independent Medical Review with the state department.
Independent Review Entity (IRE): In Medicare Advantage and Medicare drug plans, the outside organization the government hires to review a denial the plan has upheld. For Medicare Advantage the plan sends your case there automatically. For a drug plan you usually have to ask. Since 1 May 2026 the contractor is C2C Innovative Solutions, Inc.; Official wording: Independent Review Entity; Example: Your Medicare Advantage plan upholds its denial, so it sends your file to the Independent Review Entity without you asking.
Independent review organization (IRO): A group of outside doctors and reviewers, not chosen by your plan or by you, that decides external review cases. The plan pays for it, and you are not charged under the federal process.; Official wording: Independent review organization; Example: An independent review organization reads your records and your doctor's letter and decides whether your plan's denial was right.
Indian Health Service Purchased/Referred Care (PRC): Money the Indian Health Service uses to pay for care from outside providers. It is not an entitlement, and a referral does not mean the bill will be paid.; Official wording: Purchased/Referred Care (called contract health services in the regulation); Example: You were denied payment because the Indian Health Service was not told within 72 hours of an emergency admission. The denial must be in writing, and each appeal step has a 30-day limit counted from when you receive the notice.
Integrated plan (people with Medicare and Medicaid): A health plan for people who have both Medicare and Medicaid that handles appeals for both programs in one process. It applies only to certain plans, so other plans for people with both programs use the separate Medicare and Medicaid rules.; Official wording: Applicable integrated plan; Example: Your plan is an integrated plan, so one appeal can cover both your Medicare and your Medicaid benefits.
Internal appeal: Your first appeal, made to your own plan. A job-based plan has to give you at least 180 days after you get the denial notice to file. Check the date on your notice, which controls.; Official wording: Internal appeal; Example: You file an internal appeal with your plan, and a different reviewer than the first one decides it.
Itemized bill: A bill that lists each service and charge on its own line instead of one total. No general federal right to one was found for insured patients, but you can ask your provider for it and for your billing records.; Example: The hospital sends one total, so you ask in writing for an itemized bill and your billing records.

L

Level of care: The kind of setting or the amount of treatment, such as a hospital stay, an outpatient visit or a residential program. A dispute about the right level of care involves medical judgment, so it can be eligible for external review.; Example: Your plan approves outpatient treatment but denies the residential program your doctor recommended. That is a dispute about level of care.
Limitation on liability: A Medicare rule that can make Medicare pay for a service it denied as not reasonable and necessary, if neither you nor your provider knew it would not be covered. You count as knowing only if you were given written notice.; Official wording: Limitation on liability (Social Security Act section 1879); Example: Medicare denies a service as not reasonable and necessary, but you were never given written notice. This rule may protect you from the bill.

M

Managed care organization (MCO): A private company that a state Medicaid program pays to manage health care for Medicaid members. If your Medicaid is run this way, you appeal to the company first.; Official wording: Managed care organization; Example: Your Medicaid managed care organization denies a service, so you file a plan appeal with it before you can ask the state for a fair hearing.
Marketplace eligibility appeal: An appeal of a decision made by the Marketplace itself, such as whether you qualify for a plan or a tax credit. It is not the way to fight a claim denied by a marketplace insurance company. The usual limit is 90 days from the eligibility notice, and your notice controls.; Official wording: Marketplace eligibility appeal; Example: The Marketplace says you earn too much for a tax credit, so you file a Marketplace eligibility appeal.
Medicaid: A health program run by states with federal rules that covers some people with limited income and other qualifying groups. Appeals go to your plan first if you are in managed care, and then to a state fair hearing.; Example: Your Medicaid plan denies a service, so you file an appeal with the plan first.
Medical necessity: A plan's test for whether care is needed and appropriate for your condition. Plans often deny care as 'not medically necessary'. You can ask for the rule they used and the clinical reasoning.; Example: Your plan says a scan is not medically necessary, so you ask for the guideline it used.
Medical policy: A document where a plan sets out when it will cover a treatment. If your plan relied on an internal rule or guideline, you can ask for a free copy.; Example: Your denial mentions a plan guideline, so you ask for a copy of it.
Medicare Administrative Contractor (MAC): A private company the government hires to process Original Medicare claims. It also handles your first Medicare appeal, called a redetermination.; Official wording: Medicare Administrative Contractor; Example: Your Original Medicare claim is denied, and you send your first appeal to the Medicare Administrative Contractor named on the notice.
Medicare Advantage (Part C): Medicare plans run by private companies instead of Original Medicare. They have to follow Original Medicare's coverage rules, and their own appeal steps start with the plan.; Official wording: Medicare Advantage (Part C); Example: Your Medicare Advantage plan denies a hospital stay, so you ask the plan to reconsider.
Medicare Appeals Council: The fourth level of a Medicare appeal. It reviews the Administrative Law Judge's decision fresh. You ask in writing within 60 days of receiving that decision, and your notice controls.; Official wording: Medicare Appeals Council; Example: An Administrative Law Judge decides against you, so you ask the Medicare Appeals Council to review the case.
Medicare Beneficiary Ombudsman: A Medicare office that helps with complaints, grievances, appeals and information requests that your plan or 1-800-MEDICARE has not solved. To reach it, ask a 1-800-MEDICARE representative to send your issue to it.; Official wording: Medicare Beneficiary Ombudsman; Example: Your plan and 1-800-MEDICARE could not fix your problem, so you ask the representative to submit it to the Ombudsman.
Medicare Part D: Medicare's prescription drug coverage, sold through private plans.; Official wording: Medicare Part D prescription drug plan; Example: Your Part D plan will not cover a medicine, so you ask for a coverage determination.
Medicare Summary Notice (MSN): A statement Medicare sends about the claims it processed, with its decisions and how to ask for a first appeal. It is not a bill. The paper copy comes every 6 months if you got services in that time, and electronic copies are monthly.; Official wording: Medicare Summary Notice; Example: Your Medicare Summary Notice shows a denied claim and tells you how to ask for a redetermination.
Medigap (Medicare Supplement Insurance): Private insurance that helps pay costs Original Medicare leaves, such as deductibles and coinsurance. Medicare pays its share first. It cannot be used to pay Medicare Advantage copayments, deductibles or premiums. States regulate it.; Official wording: Medicare Supplement Insurance; Example: Medicare pays its part of a bill, then your Medigap policy pays its part of what is left.

N

No Surprises Act: A federal law that protects you from some surprise bills: emergency care, some out-of-network clinicians at in-network hospitals and surgical centers, and air ambulances. It does not cover ground ambulances.; Official wording: No Surprises Act (part of the Consolidated Appropriations Act, 2021); Example: You are treated at an emergency room that is out of network, and you are billed only your in-network share.
Nonquantitative treatment limitation (NQTL): A rule that limits treatment without counting dollars or visits, such as prior authorization, medical necessity rules or network rules. Plans that use these on mental health benefits have to document how they compare with medical benefits.; Official wording: Nonquantitative treatment limitation; Example: A plan requires approval before each therapy visit for mental health but not for physical therapy. That is the kind of limit the parity law looks at.
Not reasonable and necessary: Medicare's phrase when it denies a service as not medically needed. It is a different wording from a private plan's 'not medically necessary'.; Official wording: Not reasonable and necessary; Example: Your Medicare notice says a service was not reasonable and necessary, which means Medicare thinks you did not need it.
Notice of action: In Medicaid, the written notice from the state about a denial, cut or end of benefits. It must give the reasons, the rules, your right to a hearing, and when benefits continue if you ask for one.; Official wording: Notice of adverse action; Example: You get a notice of action that says your home care hours will drop, and it tells you how to ask for a hearing.
Notice of Medicare Non-Coverage: A notice that a skilled nursing facility, home health agency or similar provider gives you at least 2 days before Medicare-covered services end. It starts your right to a fast appeal to the Quality Improvement Organization, by noon of the day after you get it.; Official wording: Notice of Medicare Non-Coverage (form CMS-10123); Example: Your nursing facility gives you this notice, so you call the Quality Improvement Organization before noon the next day to appeal.

O

Observation status: When a hospital keeps you for tests or watching but treats you as an outpatient, not as an inpatient. This can change what you pay. If you were formally admitted and then switched to observation, there is a limited appeal right.; Official wording: Outpatient observation services; Example: You are formally admitted, then switched to observation. You stay in the hospital 3 days in a row but are an inpatient for fewer than 3 days. You may be able to appeal the change.
Office of Inspector General (OIG): A government watchdog inside the Department of Health and Human Services that audits health programs. Some of the statistics on this site come from its reports.; Official wording: Office of Inspector General, United States Department of Health and Human Services; Example: A report from this office found that Medicare Advantage plans overturned 75% of their own denials on appeal in 2014 to 2016.
Organization determination: In Medicare Advantage, the plan's first decision on whether it will provide or pay for a service. A refusal, an early end to treatment, or a failure to act in time can all be appealed.; Official wording: Organization determination; Example: Your Medicare Advantage plan refuses to pay for a procedure. That decision is an organization determination you can appeal.
Original Medicare: The government-run Medicare, made up of Part A and Part B. Claims go to Medicare contractors, not to a private plan.; Official wording: Original Medicare (Medicare Part A and Part B); Example: A denied claim in Original Medicare goes first to the Medicare Administrative Contractor.
Out-of-network: Providers who do not have an agreement with your plan. Plans often pay less for them, or nothing.; Example: You see a doctor who is out of network, and your plan pays a smaller share.
Out-of-pocket maximum: The most your plan says you have to pay in a year for covered care. Check your plan document for what counts toward it.; Example: Your plan's out-of-pocket maximum is $5,000 (example amount), and after you reach it the plan pays for covered care for the rest of the year.

P

Parity: A law that says your plan cannot make mental health and substance use care harder to get than medical and surgical care. Your plan has to be able to show how it compares them.; Official wording: Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA); Example: Your plan sets approval rules for therapy that are tougher than the rules for similar medical care. If it is an employer plan, you can ask for its written comparison.
Part D coverage determination: In Medicare drug plans, the plan's first decision on a drug request: whether it will cover a drug or pay you back. A request for an exception starts here too. The plan has to answer in 72 hours, or 24 hours for a fast request.; Official wording: Coverage determination; Example: You ask your drug plan to cover a medicine, and its answer is the coverage determination. If it says no, the next step is a redetermination.
Patient-provider dispute resolution: A process for people who are uninsured or paying themselves to dispute a bill when the charges are at least $400 more than the provider's good faith estimate. You start it within 120 days of the first bill, and there is a fee ($25 as of 11 November 2026).; Official wording: Patient-provider dispute resolution; Example: A provider's bill is much higher than its estimate, so an uninsured patient starts the dispute process.
Peer-to-peer review: A phone call where your doctor talks directly with the plan's doctor about a denial. Many plans offer it before a formal appeal.; Example: Your doctor calls the plan's reviewing doctor to explain why you need the treatment.
Plan administrator: The person or organization named in your plan document to run the plan. If none is named, it is the plan sponsor. Written requests for plan documents go to the administrator.; Official wording: Plan administrator; Example: You write to your plan administrator and ask for your plan's latest summary plan description.
Plan sponsor: The organization that offers the plan, usually your employer.; Official wording: Plan sponsor; Example: If your employer's plan is self-funded, your human resources office may be able to ask the plan sponsor to look at your case again.
Post-service claim: A claim for payment of care you already got. For a job-based plan, the first decision is due within 30 days, with one possible extension of up to 15 days.; Official wording: Post-service claim; Example: You get a bill for a visit that already happened, and your plan must decide the claim within its time limit.
Pre-service claim: A request for approval before you get care, such as prior authorization. For a job-based plan, the first decision is due within 15 days, or 72 hours if it is urgent.; Official wording: Pre-service claim; Example: Your doctor asks the plan to approve surgery before it is scheduled. That is a pre-service claim.
Prior authorization: Your plan's approval before you get certain care or drugs. It is also called prior approval or preauthorization. A plan cannot require it for emergency services, and cannot deny a claim for missing approval if getting approval was impossible.; Example: Your plan denied a scan claim because no approval was on file, so you ask the plan why approval was needed and whether the request can still be reviewed.
Provider directory: A plan's list of providers in its network. If you relied on a wrong listing, your plan may not charge more than in-network cost sharing.; Example: The directory said a doctor was in network, but she was not. You can ask the plan to treat the visit as in network.
Prudent layperson standard: The test for an emergency: would an ordinary person with average health knowledge reasonably expect that waiting would be seriously dangerous? It looks at your symptoms, not the final diagnosis.; Official wording: Prudent layperson standard; Example: You went to the emergency room with severe symptoms. The visit was judged on those symptoms even though the final diagnosis turned out to be minor.

Q

Qualified Independent Contractor (QIC): The second level of an Original Medicare appeal: an outside contractor that reviews your case if you disagree with the redetermination. You have 180 days from receiving the redetermination notice to ask, and your notice controls.; Official wording: Qualified Independent Contractor; Example: The Medicare Administrative Contractor upholds its denial, so you ask the Qualified Independent Contractor for a reconsideration.
Quality Improvement Organization (QIO): A group of doctors and reviewers under contract with Medicare that handles fast appeals of hospital discharges and service endings, and quality-of-care complaints. It is free to use.; Official wording: Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO); Example: You think you are being sent home from the hospital too soon, so you call the Quality Improvement Organization for your state before you leave.
Quantity limit: A cap on how much of a drug your plan will cover over a period of time.; Example: Your plan covers 30 pills a month (example amount), but your doctor prescribed more, so you ask for an exception.

R

Reconsideration: The Medicare name for a second look. In Medicare Advantage it is your first appeal, filed with the plan. In Original Medicare it is the second level, done by an outside contractor.; Official wording: Reconsideration; Example: Your Medicare Advantage plan denies a service, and you file a reconsideration within 65 days of the date on its notice. The rule says 60 days from receipt, and receipt is presumed 5 days after the notice date.
Redetermination: The first Medicare appeal. In Original Medicare you send it to the Medicare Administrative Contractor within 120 days of getting the notice. In a Medicare drug plan you send it to the plan.; Official wording: Redetermination; Example: Your Medicare Summary Notice shows a denial, so you request a redetermination. Check the deadline on your notice, which controls.
Referral: A doctor's recommendation or request for you to see a specialist or get a service. Some plans require one before they pay.; Example: A claim is denied because you saw a specialist without a referral your plan requires.
Rescission: When a plan cancels your coverage back to a past date, as if you never had it. It is allowed only for fraud or an intentional misstatement of an important fact, with at least 30 days of written notice. Cancelling for unpaid premiums is not a rescission.; Official wording: Rescission of coverage; Example: Your plan sends a notice that it is cancelling your coverage back to its start date. You can appeal that and take it to external review.

S

Self-funded plan: A job-based plan where the employer pays claims from its own money, often with an insurance company only handling the paperwork. State insurance laws usually cannot be applied to it, and complaints go to a federal agency instead.; Official wording: Self-funded (self-insured) plan; Example: Your employer pays claims itself, so your complaint goes to the federal Employee Benefits Security Administration, not your state insurance department.
Short-term, limited-duration insurance: Coverage sold for a short period. The federal Affordable Care Act appeal and external review rules and the No Surprises Act do not apply to it, so any appeal rights come from the policy and state law.; Official wording: Short-term, limited-duration insurance; Example: A short-term policy denies a claim, so you read the policy and ask your state insurance department what appeal rights you have.
State Health Insurance Assistance Program (SHIP): A state program with free, one-on-one Medicare counseling that is not connected to any insurance company. Find yours at shiphelp.org or by calling 877-839-2675.; Official wording: State Health Insurance Assistance Program; Example: You call your State Health Insurance Assistance Program and a counselor helps you read your Medicare denial.
State insurance department: The state agency that regulates insurance companies and the policies they sell. Complaints about an insurance company go here. It does not regulate self-funded employer plans.; Official wording: State department of insurance (the name varies by state); Example: Your fully insured plan ignores your appeal, so you file a complaint with your state insurance department.
Step therapy: A plan rule that you must try a cheaper drug first, and have it fail, before the plan pays for the drug your doctor prescribed. It is also called fail first. You can ask for an exception.; Example: Your plan wants you to try two other drugs first, so your doctor sends an exception request explaining why they will not work for you.
Summary of Benefits and Coverage (SBC): A short summary of what a plan covers and what you pay. It is a good place to check whether your plan excludes the service you were denied.; Official wording: Summary of Benefits and Coverage; Example: You check your Summary of Benefits and Coverage to see whether physical therapy is listed as an exclusion.
Summary plan description (SPD): A document that tells you how a job-based plan works, including its claim and appeal steps and time limits. The plan administrator has to give you the latest copy if you ask in writing.; Official wording: Summary plan description; Example: You read your summary plan description to find out how many appeal levels your plan has.
Surprise bill: An unexpected bill from an out-of-network provider after care you thought was in network. The No Surprises Act limits you to your in-network share in covered situations.; Example: You have surgery at an in-network hospital and get a bill from an out-of-network assistant surgeon. You can ask that you be charged only your in-network share.

T

Tier: A level on a plan's drug list. Drugs in higher tiers usually cost you more. A tiering exception asks the plan to charge you the price of a lower tier.; Example: Your drug is on a high tier, so your doctor asks for a tiering exception.
Timely filing: A deadline for sending in a claim. A claim sent after the deadline can be denied for being late.; Example: A claim is denied for late filing because the provider sent it after the plan's time limit.
Transition fill: In the first 90 days with a new Medicare drug plan, a one-time temporary supply of a drug that is not on the plan's list, or that needs approval or step therapy. The temporary supply is at least an approved month's supply, and the plan must send written notice within 3 business days.; Official wording: Transition fill; Example: You join a new drug plan and your medicine is not on its list, so you ask for a transition fill while you ask for an exception.
TRICARE: Health coverage for military service members, retirees and their families. Appeals begin with a written request to the TRICARE contractor, due within 90 days of the date on the decision, and your notice controls.; Official wording: TRICARE; Example: TRICARE denies a claim, so you mail a written reconsideration request to the contractor within 90 days of the date on the decision.

U

Urgent care claim: A claim where waiting the normal time could seriously harm your life, health or ability to regain full function, or where a doctor who knows your condition says it would cause severe pain. This is about the situation, not about visiting an urgent care clinic. The plan must decide as soon as possible and within 72 hours.; Official wording: Claim involving urgent care; Example: Your doctor tells your plan your treatment is urgent, so the plan has to treat the claim as urgent.
Usual and customary: One way plans work out the allowed amount for out-of-network care, based on what providers in an area typically charge. Other ways include the Medicare rate and a fee schedule.; Example: Your plan says a provider charged more than the usual and customary amount, so it paid only the lower amount.
Utilization review: A plan's process for checking whether care is needed. It can happen before care, while you are getting it, or after.; Example: Your plan's utilization review decides whether to approve your hospital stay.

Sources last checked 12 November 2026. Found a mistake? Report it.