Understanding Insurance Verbiage:
Determination/Verification of Benefits – Means we have verified and confirmed with the carrier specific benefits that are available based on the patient’s health benefit plan. Determination of benefits is not a guarantee of payment.
Pre-Certification – Means we can perform a specific procedure, but it is not a guarantee of payment.
Prior Authorization: Means your service will be paid. Prior authorization from the carrier has to be obtained and provided in writing. Prior Authorization is a guarantee for payment.
What is a PCP – A PCP is a family physician, family practitioner or general practitioner that is responsible for delivering or coordinating care.
Participating Provider – A healthcare provider who has a written agreement (contract) with an insurance carrier to provide covered services to its members.
Individual Deductible – The amount of money the patient is responsible to pay out of pocket before insurance company will start to pay. The deductible is usually paid once per calendar year (Jan-Dec).
Family Deductible – Under this arrangement, if the designated number (2-3) of the family members meet the deductible in full then the deductible is deemed satisfied for all family members.
Annual Out of Pocket (OOP) – This is a set dollar amount that the insured must pay for all medical costs before an insurance plan pays 100% of the bill.
Copay – The fixed dollar amount that a patient is required to pay as their share of the cost of certain services each time they receive care from a participating provider.
Coinsurance – Cost-sharing requirement that the insured pay a designated percentage of the allowed amount for covered services.
Carry Over Deductible – If an insured should meet their deductible in the last three months of the year, it will carry over (rollover) to the following year. (It is very rare that carriers provide this benefit).
Maximum Lifetime Coverage – The maximum benefit amount that a carrier will pay out in an insured’s lifetime. Once the maximum benefit amount has been reached, there is no longer any coverage available under that policy.
Pre-Existing Condition Clause – Is a pre-existing condition that was in effect six months prior to the effective date of the policy. It can only be excluded for one year after the effective date of the policy.
Exclusion – An item, service, procedure or diagnosis not covered by the carrier.
Covered In-Network – What % of the services is covered if the provider is in-network?
Covered Out-of-Network – What % of the services is covered if the provider is out-of-network?