Glossary of Terms

Definitions of Health Insurance Terms

Carrier- The insurance company

In-network Provider- This is a provider that has a contract with your insurance company with all the agreed upon amounts of payment for every service. The provider agrees not to bill you beyond this agreed upon amount. * Ask “Are you an In-network provider with …”, and not simply, “do you accept United HealthCare”

Out-of Network- Steer clear of these provider’s if possible. This is a provider that does not have any contract or agreed upon amount with your Carrier to charge you for their service. You are responsible for meeting a new and higher deductible, and the remaining balance that the provider bills you over and above the In-network contracted amount.

Deductible - The amount of the claim you must pay 100% of before coinsurance kicks in

Coinsurance - The percentage of the allowed amount paid once the deductible is satisfied. 80% coinsurance means the insurance company pays 80%, and you pay the other 20% of the allowed amount after you satisfy your deductible.

Max out of Pocket - The total annual dollar amount you have to pay out of your pocket, (subject to the rules of your plan), before the plan pays 100% of all your allowed charges on the medical bills.

Office Copay- The flat dollar amount you pay a doctor for a service without having to meet the deductible or paying any coinsurance. There may be two levels of copays, one amount for regular doctor office visit, and a higher copay to see a specialist.

Discount - The difference between the billed amount and the PPO network negotiated amount.

Allowed Amount- The PPO negotiated dollar amount dictated by the insurance company as agreed upon by the doctor’s contract with the insurance company. Non-network providers may be limited to the Reasonable & Customary charge or some lesser amount.

Claim- The bill that the doctor sends the insurance company for a date of service.

EOB- The Explanation of Benefits Statement that the insurance company sends you and the provider to show how that claim was processed, and what you are responsible for paying yourself.

Effective Date- The exact date your policy began.

 
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