In the Medicare program, this was formerly referred to as the appeal process . If a patient disagrees with any decision about health care services or if Medicare does not pay for an item or service, the initial Medicare decision may be reviewed again using this process. It has five levels: (1) redetermination (telephone, letter, or CMS-20027 form); (2) hearing officer (HO) hearing or reconsideration; (3) administrative law judge (ALJ) hearing; (4) Departmental Appeal Board review; and (5) judicial review in U.S. District Court.

Civil rights issue wherein an insurance company denies coverage to questionable or high risks in a given geographical area.
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Unfair discrimination based not on the risk’s characteristics but on its location. The term is commonly associated with an insurer’s refusal to consider insuring any home or business within a specific area marked by a line drawn on a map.

Provision in an insurance policy that reduces the level of life insurance to another amount of coverage. This situation can occur when the insured reaches a specific age or retires.

Inactive membership in an insurance plan that is reestablished using the same subscriber identification number and may be in the same group or a new group.

Diagnostic laboratory tests performed on samples that are referred to the hospital laboratory.

1. Transfer of the total or specific care of a patient from one physician to another. 2. In managed care, a request by the primary care physician for authorization for a member to receive care from a specialist or hospital or get certain services. In some managed care plans, a member may need an approval from the primary care physician to a specialist for insurance coverage. 3. Document obtained from a provider or plan-approved caregiver so that a plan enrollee may receive additional medical services from a specific place/person.

Verbal or formal written document that gives approval to a managed care plan member to obtain medical services outside of the network of participating providers (e.g., primary care physician approves a plan member to see a specialist).

Telephone service staffed by nonclinical personnel that directs patients to approved hospital facilities and physicians and may also perform triage. Managed care plans use these call centers to communicate with patients and providers and sometimes to precertify or preapprove care. Usually the center has a toll-free 800 number for easy access and no charge to health plan members. Also known as call center, 24-hour certification, or triage .