Billing & Insurance Terms

Sometimes billing and insurance terms can leave you feeling like you’re learning a second language. We’re here to help! Below is a list of commonly used terms you might see regarding your healthcare billing and insurance claims.

Important Definitions to Understand

Copay 

Fixed dollar amount a patient pays for covered health care.

Coinsurance

Patient share of the costs of a covered service, calculated as a percent of the allowed amount for the service. Example: If the plan’s allowed amount for an office visit is $100, patient co-insurance payment of 20% would be $20.00.

Deductible 

A deductible is the amount you must pay for covered services before the insurance starts covering your cost.  Screenings, immunizations and preventative services are covered without requiring you to pay a deductible. If you are unsure of your coverage, please contact your insurance company.

When you are insured on a family plan, please review the type of deductible-traditional or aggregate. Health plans with traditional deductibles have 2 separate deductibles: an individual and a family deductible. The individual deductible allows each member of a family to receive benefits from the insurance company before the family deductible has been satisfied.

If your family is on an aggregate deductible plan, the entire family needs to satisfy the deductible before any members of the family receive benefits. This type of plan is usually seen in high deductible plans tied to a health savings account.

Out of Pocket Limit

This is the most a you could pay during a covered period (usually 1 year) for your share of covered services. If you are unsure of your limit, please contact your insurance company with questions.

In-Network

“Participating” or “In Network” providers are those contracted with your carrier. You pay a lower co-insurance and deductible when they use an in-network provider. We do our best to verify coverage prior to your visit but your carrier states it is your responsible to verify you are scheduled with an “in-network” provider by checking online or calling your carriers customer service line listed on the backside of your insurance card.

Out-of Network

If a provider or pharmacy is not listed as an “in-network” or “participating provider”, you will  have a higher out of pocket cost for the service(s) rendered. Please contact the customer service number on the back of your card for the exact amount. The deductible and co-insurance will be higher than in network providers.

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