This glossary has many commonly used terms, but isn’t a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions you come across.
Health and Medical Terms
Listed below is a summary of some commonly used terms you may find in working with your insurance coverage and medical providers such as doctors, dentists, and medical specialists. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs.
Billing and Payments
Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference.
This will occur when a provider (doctor or medical/dental service) bills you for the difference between the amount they charge and the allowed amount (the amount the doctor agrees to accept as payment in full if they are under contract with an insurance company). For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. Balance billing should not occur if the provider is under contact (and most are) with the insurance carrier.
Please ask the provider if they accept your insurance coverage by showing the office your Member ID card prior to services being rendered.
Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount. Please visit this page to understand how co-insurance works.
A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
The initial amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services. Please note that the University of Pittsburgh student insurance plans do not have a deductible for in-network services. Please visit this page to understand how a deductible works.
The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance.
A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments.
The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Out-of-network co-insurance usually costs you more than in-network co-insurance.
A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network copayments usually are more than in-network co-payments.
The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit. Please visit this page to understand how out-of-pocket limits work.
This is the most you will have to pay each plan year before the plan begins to pay 100 percent of reasonable and customary covered expenses. Out-of-pocket maximums exclude deductibles, co-payments, prescription drug expenses, pre-certification penalties and amounts over reasonable and customary charges.
The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly. Student Health Insurance is usually paid monthly.
Prescription Drug Coverage
Most health insurance plans usually pay towards the cost of prescription medication. Your cost share is typically a co-payment (a flat dollar amount) or a percentage of the total costs (e.g. 20%).
Reasonable and Customary Charges
The amount determined to be a reasonable expense for certain medical services. This amount is determined by UPMC Health Plan and is based on regional and national data. Amounts above the reasonable and customary charge are the financial responsibility of the member receiving such services.
UCR (Usual, Customary, and Reasonable)
The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount.
Care and Services
Convenient Care Clinics (i.e. MinuteClinic)
At a convenience care clinic (such as one found in a drug store), you may be seen by a Certified Nurse Practitioner or Physician Assistant. A convenience care clinic may treat things such as: minor infections, ear and sinus infections, skin conditions (e.g., poison ivy), and minor injuries such as a splinters or sprains.
Care is considered coordinated (in-network) when it is performed or authorized by your PCP. If you choose to obtain medical care through another physician, either in- or out-of-network, this care will be considered self-referred because it is not coordinated through your PCP. Coordinated care benefits apply if authorized by your PCP. If not authorized, then self-referred care benefits apply. No benefit will be payable for self-referred care under the Panther Gold plan outside the UPMC Health Plan Network.
Disability Resources and Services (DRS)
DRS provides equal opportunities and support services for academically qualified students with disabilities to ensure they are integrated as fully as possible into the University experience. Their services include providing assistive technology, specialized exam accommodations, interpreters and real-time captioning, assistance with transportation and specialized housing accommodations. DRS is located on the first floor of the William Pitt Union and can be contacted at 412-648-7890.
Emergency Medical Transportation
Ambulance services for an emergency medical condition.
Emergency Room Care
Emergency services you receive in an emergency room. Emergency rooms are situated in a hospital setting.
Evaluation and treatment of an emergency medical condition that may prevent this acute situation from getting worse.
There is a list of health care services that your insurance plan does not cover. They may be found in the Certificate of Coverage on this web site. Any excluded services received are the responsibility of the member.
Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.
Home Health Care
Health care services a person receives at home.
Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
Hospital Outpatient Care
Care in a hospital that usually doesn’t require an overnight stay.
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care.
Services performed by participating providers who have a contract or agreement with UPMC Health Plan or other insurance plan to provide specific services for a specific cost.
International Student Organizations and Programs
International student organizations and programs are housed on the sixth floor of the William Pitt Union in the Office of Cross-Cultural and Leadership Development (CCLD). Through this office, international students attend culture shock and adjustment workshops, social events, and information and educational programs. New international students participate in the LINKS program to aid in their adjustment to Pitt through CCLD. CCLD also serves as the advisor for numerous international student organizations.
Health care services received outside of the designated PPO network by non-participating providers. Benefits are paid at a lower level after the annual deductible is met. Members may also have to pay the difference between the provider’s charge and the UPMC Health Plan payment.
Care in a hospital or other outpatient facility that usually does not require an overnight stay.
Health care services a licensed medical physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or coordinates.
Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
Skilled Nursing Care
Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home.
Student Health Services
(SHS) is a primary care facility that features a health care clinic and pharmacy staffed by medical doctors, nurses, nurse practitioners, a pharmacist, and other health care professionals. Each student pays a student health fee each semester that gives them access to SHS, which also provides a comprehensive array of educational programs and preventative medicine, including women’s health services. SHS is located in the Medical Arts Building at 3708 Fifth Avenue (beside Rita’s) and their number is 412-383-1800. Students at the regional campuses should check their campus directory for the telephone number and location.
University Counseling Center
Provides comprehensive and confidential personal and academic counseling to Pitt students free of charge. Staffed by psychologists, counselors, social workers, psychiatrists, and pre-doctoral interns, the counseling center provides personal and group counseling for a variety of conditions including ADHD/ADD, depression, drug and alcohol support, anxiety, grief, sexual abuse, and more. The counseling center has day and evening hours by appointment and is located on third floor of the William Pitt Union. Please call 412-648-7930 for more information.
Urgent Care (i.e. UPMC Urgent Care & MedExpress)
Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. At an urgent care center you may be seen by a physician or a nurse practitioner, but a physician is generally always on site. An urgent care clinic may treat injuries or illnesses that need more immediate care but are not serious enough to go to an emergency room. These include all of the convenience clinic treatments plus a broader range of treatments and tests such as x-rays, setting broken bones, and stitches. Highfield Urgent Care is subject to deductible and co-insurance.
Provides nitrous oxide, oral sedation, intravenous (IV) sedation and/or general anesthesia.
Provides dental prophylaxis (teeth cleaning) and preventive services, such as application of topical fluoride treatments and sealants; educates and counsels patients about proper oral hygiene techniques, nutrition, and tobacco cessation.
Provides emergency dental care (pain, bleeding, swelling, infection).
Endodontics (Root Canal)
Provides treatment of tooth infections of the pulp caused by decay or injury.
Provides replacement of missing teeth using dental implants and implant-supported or implant-retained prostheses.
New Patient Screening
Includes examinations and assessments of oral health needs, including medical factors.
Oral and Maxillofacial Surgery
Provides diagnosis and surgical and adjunctive treatment of diseases, injuries, defects, and aesthetic problems involving the teeth and other structures associated with the oral and maxillofacial regions.
Orthodontics and Dentofacial Orthopedics
Provides diagnosis and specialized treatment of oral and facial malformations, including braces.
Pediatric Dentistry (All patients less than 18 years of age)
Provides preventive and comprehensive dental treatment for children and adolescents.
Provides services ranging from prophylaxis (teeth cleaning) to the treatment of periodontal disease (gum disease) including scaling and root planing (deep cleaning), as well as specialized treatment such as periodontal surgery, bone grafts, soft tissue grafts, implants, and managing of temporomandibular joint (TMJ) disorders.
Provides services ranging from single unit crowns to multiple units of crowns (bridges), removable complete dentures, and removable partial dentures to replace missing teeth.
Provides imaging services that include radiographs of teeth and supporting structures (intra-oral); 3D imaging of selected areas for certain diagnostic tasks such as study of potential implant sites, temporomandibular joints, etc.; appropriate referrals for advanced imaging at UPMC hospitals or other such imaging centers in select cases, upon request from the care provider; radiographs are read by radiology faculty and written reports are provided, when specifically requested.
Provides restorations (fillings), such as silver amalgam, gold, composites (white fillings), and porcelain inlays, onlays, and veneers.
A request for your health insurer or plan to review a decision or a grievance again.
Complications of Pregnancy
Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a nonemergency caesarean section aren’t complications of pregnancy.
A spouse or an unmarried child under 26 years of age.
Durable Medical Equipment (DME)
Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics.
Emergency Medical Condition
An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.
A complaint that you communicate to your health insurer or plan.
A contract that requires your health insurer (e.g. UPMC Health Plan, Aetna, United Health Care, Highmark) to pay some or all of your health care costs in exchange for a premium.
Mail-Order Prescription Drugs
Medications that can be ordered in a 3-month or 90-day supply for a reduced out-of-pocket cost. Please note that if you have coverage through UPMC Health Plan, you may obtain a 90-day supply at Student Health Services (SHS) and Falk Pharmacy.
Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
A benefit your employer, union or other group sponsor provides to you to pay for your health care services.
This is the notification that must be given to UPMC Health Plan prior to inpatient and certain outpatient services being obtained. If you or your physician does not pre-notify UPMC Health Plan, you may be subject to a $500 penalty. Please see plan design grids to determine who is responsible for pre-notification, either you or the participating network physician.
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.
Preferred/Non-Preferred Brand Prescription Drugs
The Prescription Drug Program now includes Preferred Brand and Non-Preferred Brand medications. Please call UPMC Pharmacy Services at 1-800-396-4139 for details.
Prescription Drug Coverage
Health insurance or plan that helps pay for prescription drugs and medications.
Drugs and medications that, by law, require a prescription.
Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions.
Specialty Prescription Drugs
Specialty medications are used to treat complex clinical conditions and are limited to a 30-day supply. Most specialty medications must be obtained through our designated specialty provider, which provides convenient and expedited delivery through the mail.
Networks and Providers
Specific network of UPMC facilities and services. Applies to Panther Gold plan only.
The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
A provider that has not contracted with UPMC Health Plan to provide services at a reduced fee.
A provider who doesn’t have a contract with your health insurer or plan to provide services to you. You’ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers.
Physicians and/or facilities that do not belong to the UPMC Health Plan network of participating providers.
A provider that has contracted with UPMC Health Plan or other insurance carrier to provide medical services to covered persons. The provider may be a hospital or other facility, a physician, or a pharmacy that has contractually accepted the terms and conditions as set forth by UPMC Health Plan or any other contracted insurance carrier.
A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also “participating” providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more.
Preferred Provider Organization (PPO)
An arrangement between a group of doctors or providers and another entity, such as an employer or other group. This arrangement makes it possible for price discounts on services in exchange for a higher volume of patients. Please make sure your physicians and other health care service providers or facilities participate with your insurance coverage. Most providers and facilities in Western PA contract with UPMC Health Plan but it is always a good idea to confirm the arrangement.
Primary Care Physician
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient.
Primary Care Provider
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates, or helps a patient access a range of health care services.
A physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law.
A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more experience in a specific area of health care.
UPMC Health Plan Network
Participating hospitals and physicians, including the Advantage Network.