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Appeals glossary

The shorthand insurers and regulators use, in plain English. Each term links to the guide where it matters most.

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ERISA: The Employee Retirement Income Security Act of 1974, the federal law that governs most employer-sponsored health plans and sets your appeal rights and deadlines.; See ERISA appeals guide
ACA: The Affordable Care Act, which governs individual and marketplace health plans and guarantees internal appeals plus an independent external review.; See ACA appeals guide
No Surprises Act (NSA): A federal law that shields patients from many surprise and balance bills for out-of-network emergency care and certain services at in-network facilities.; See No Surprises Act guide
Independent Dispute Resolution (IDR): The federal arbitration process that providers and insurers use to settle out-of-network payment disputes under the No Surprises Act.; See NSA open negotiation and IDR
Qualifying Payment Amount (QPA): The insurer's median contracted rate for a service, used as the benchmark in No Surprises Act payment disputes.; See No Surprises Act guide
Summary Plan Description (SPD): The plan document that spells out your benefits, exclusions, and the exact appeal procedures and deadlines for an ERISA plan.; See ERISA appeals guide
Medical necessity: The standard insurers use to decide whether care is appropriate and covered. Clinical practice guidelines are the strongest evidence for it.; See proving medical necessity
Internal appeal: Your formal request asking the insurer to reconsider a denial. You generally must complete this before external review.; See compare appeal types
External review: An independent review of a denied claim by a reviewer outside your insurer, available after you exhaust internal appeals.; See ERISA appeals guide
Independent Review Organization (IRO): An independent medical reviewer, not affiliated with your insurer, whose external-review decision is binding on the plan.; See ERISA appeals guide
De novo review: A fresh review from scratch, in which the reviewer is not bound by the insurer’s earlier decision.; See urgent ERISA appeal
Self-funded plan: An employer plan that pays claims from its own funds rather than buying insurance. These are usually governed by ERISA.; See ERISA appeals guide
COBRA: A law that lets you keep employer health coverage after leaving a job. COBRA coverage is generally treated as ERISA.; See ERISA appeals guide
Balance billing: When an out-of-network provider bills you for the difference between their charge and what your insurer paid.; See No Surprises Act guide
Repricer: A third-party vendor (such as Zelis, MultiPlan, Claritev, or Data iSight) that insurers hire to recalculate, and often reduce, out-of-network payments.; See out-of-network underpayments
Reference-Based Pricing (RBP): A pricing method that pays out-of-network claims against a benchmark, such as a multiple of Medicare, rather than the billed charge.; See out-of-network underpayments
CO-45: A claim adjustment code meaning the charge exceeds the allowed amount, a common sign that an out-of-network claim was repriced.; See out-of-network underpayments
Explanation of Benefits (EOB): The statement from your insurer showing what was billed, allowed, paid, and denied for a claim. The first place to look for a denial or underpayment.; See out-of-network underpayments