Understanding Insurance - Insurance Definitions

Allowed Amount

The amount the insurance company pays for a service (may be less than what we have billed).

Authorization / Pre-Authorization

Formal approval by insurance to assist patient and provider in securing payment for health care services.

Charge

Price for services rendered.

Co-insurance

Amount you pay to share the cost of covered services after your deductible has been paid.

Contractual Allowance / Adjustment

The difference between what an insurance company approves according to its contract and what the health care provider charges for the service.

Co-payment

One of the ways you share in your medical costs. You pay a flat fee for certain medical expenses (i.e. $20 for every visit to the doctor, while your insurance pays the rest).

CPT Code

Five digit code(s) used to describe the service being performed.

Cost

Patient's out-of-pocket responsibility for services rendered.

Deductible

A specific dollar amount that your health insurance company may require you to pay out of pocket each year before your health insurance plan begins to make payments.

EOB/EOP/EOM/MSN

Documents showing a detailed listing of how your insurance company is processing the services rendered.

Non-covered Service

A service, test, supply, or procedure that is not a benefit in a patient's health insurance policy. Patients are responsible for paying for all noncovered services. The insurance company can give the details of what test, procedure, or service is not covered.

OON - Out of Network

Health care rendered to a patient outside of the health insurance company's network of preferred providers. In many cases, the health insurance company will not pay for these services. Emergency medical care is usually an exception to the OON rule.

Established Patient

For billing purposes, an established patient is defined as someone who has been seen by the provider/department within the last three years.

New Patient

For billing purposes, an established patient is defined as someone who has not been seen by the provider/department within the last three years.

HMO - Health Maintenance Organization

An HMO requires the member to choose a provider network and a Primary Care Provider (PCP) within the chosen network. An approved referral from his/her PCP must be in place for a member to see a specialist. If a referral is not in place prior to receiving non-emergent care, the HMO may not cover incurred services.

Insurance

Coverage that pays for medical and surgical expenses incurred by the insured and/or eligible dependents.

Referral

An insurance pre-approval required from the patient's PCP BEFORE seeing a specialist.

Out-of-Pocket Maximum

The most money you will pay during your coverage period, includes deductibles, co-payments, co-insurance and balance-billed charges, but is in addition to your regular premiums.

POS - Point of Service Program

A POS has the same requirements as an HMO. However, members are given the additional option of self-referring outside of their PCP network. Members who choose to self-refer will incur a higher out of pocket cost.

PPO - Preferred Provider Organization

A PPO offers a network of providers. Members have the freedom to access a number of providers but are given financial incentives (i.e., lower out-of-pocket costs) to use the preferred provider network.

Price

Price of premiums, price of services.

Primary Care

General Internal Medicine, Family Practice and Pediatrics.

Prior-authorization

A request for payment authorization submitted in advance by a health care provider to the insurance plan for their approval to admit a patient, perform a procedure or provide a service. Pre-authorization / prior-authorization requirements are specific to each insurance plan. The insurance plan will determine medical necessity, appropriateness of services and level of care based upon their own guidelines.

Self-refer

An insurance member’s ability to obtain specialty care services without written referral from member’s primary care provider and approval from their insurance. These services, however, may be denied or paid at a lesser benefit.

Medicare A

Medicare Part A provides payments for inpatient hospital services, excluding those of physicians and surgeons.

Medicare B

Part B provides payments to physicians and surgeons, as well as for medically necessary outpatient hospital services (such as ER, laboratory, X-rays and diagnostic tests) and certain durable medical equipment and supplies.

Medicare Advantage plan

Medicare Advantage plans are private health plans that have contracted with Medicare. These plans are paid fixed subsidies by Medicare to provide Medicare beneficiaries benefits. Most of these plans are managed care plans, which are plans that control both the financial and health services aspect of the insurance plan.

Qualifying Life Event (to change insurance)

A change in your life that can make you eligible for a Special Enrollment Period to enroll in health coverage. Examples of qualifying life events are moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry, divorce, or have a baby) and gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder.