To determine before treatment the maximum dollar amount the insurance company will pay for surgery, consultations, postoperative care, and so forth.

In dental policies, a clause specifying that when dental care is expected to exceed a certain level, the dentist must submit a proposed treatment plan to the insurance company so that a determination can be made of how much the dental plan will pay. Also called preauthorization of benefits provision, precertification of benefits provision, or pretreatment review provision.

Comparison of state laws to the Health Insurance Portability and Accountability Act (HIPAA) by an organization (hospital facility), usually performed annually. State laws that are stricter supercede HIPAA privacy and security regulations. Areas in which state laws are typically more stringent include mental health and substance abuse, child abuse, elder abuse, domestic violence, AIDS/HIV, sexually transmitted diseases, genetics, and reproductive rights.

Illness or injury acquired by the patient before enrollment in an insurance plan such as chronic illness, injury, and possible pregnancy. In some insurance plans, preexisting conditions are either excluded from coverage temporarily or permanently, may disqualify membership in the plan, or may cover them only after a waiting period. Federally qualified health maintenance organizations cannot limit coverage for preexisting conditions.

Exclusion from insurance coverage or coverage after a waiting period of illness or injury received by the insured before enrollment in an insurance plan. Also called preexisting condition exclusion.

Clause in an insurance contract that states until the insured has been covered under the policy for a certain period, the insurance company will not pay benefits for any preexisting conditions.