Acronym
SME
Subject Matter Expert
This is the document showing how a claim processed and what the member owes.
Explanation of Benefits (EOB)
This is the fixed amount a member pays at the time of service.
Copay
This term describes providers contracted with the member’s plan.
In-network
This type of visit includes screenings and checkups with no cost share when billed correctly.
Preventive/Preventative Care
PHI
Protected Health Information
These codes describe medical procedures on a claim.
CPT Code/s
This is the percentage a member pays after meeting their deductible.
Coinsurance
This type of provider manages a member’s overall care and referrals.
Primary Care Physician (PCP)
This type of care is for sudden illnesses or injuries that need quick attention but aren’t life‑threatening.
Urgent Care
NPI
National Provider Identifier
This type of claim is submitted when a provider is not contracted with the plan.
Out-of-network claim
This is the maximum a member will pay out of pocket for covered services in a plan year.
Out-of-pocket maximum
HIPAA
Health Insurance Portability and Accountability Act
This term describes the amount a provider bills before the plan applies contracted rates.
Billed Amount/Charge
This service type includes procedures or treatments that do not require an overnight stay.
Outpatient Care
CVS
Consumer Value Stores
This is the portion of a billed charge that a provider or business agrees to cancel and remove from their accounts receivable because it will not be collected
Write-Off