Key Terms
What is a Copay?
A flat dollar amount a client pays per session.
What is Coordination of Benefits (COB)?
A process to determine which insurance plan pays first when a client has multiple policies.
What is an individual plan?
A health plan that only covers one person.
The client has $300 left on their $1,000 deductible. How much more must they pay?
$300 before insurance begins covering costs.
What is a CPT code?
A billing code that indicates the type of service (e.g., 90837 for therapy).
What is coinsurance?
A percentage of the session fee the client is responsible for paying.
What is a cost-share waiver?
An exception that temporarily removes client responsibility for session costs, such as during COVID.
What is a family deductible?
The total amount a family must pay before insurance starts paying.
The client has 20% coinsurance. If a session is $120, how much do they pay?
$24 per session.
What is a claim?
A request for payment submitted to insurance after a session.
What is a deductible?
The amount a client pays out of pocket before insurance begins to pay.
When might you see $0 per session in benefits?
If there's a cost-share waiver or the OOP max has been met.
How does OOP max work in a family plan?
Once the family meets the family OOP max, insurance covers 100% for everyone.
The session is $100. Deductible is met. Coinsurance is 10%. What does the client pay?
$10 per session.
What is an EPID?
An internal Headway identifier for a client’s insurance policy.
What is an out-of-pocket max?
The most a client will pay in a plan year before insurance covers 100%.
Why is verifying the CPT code important during a benefits check?
It ensures the session type (e.g., therapy) is actually covered.
Why ask about deductible reset dates?
To understand when a new plan year starts and benefits reset.
The deductible is $1,000. Sessions are $200 each. How many sessions before it's met?
5 sessions.
What is a DX code?
A diagnostic code used to justify medical services (e.g., F33.1 for depression).
What is cost-share?
The portion of session costs the client is responsible for (copay, coinsurance, deductible).
What does ‘Outpatient Only’ coverage mean?
The plan covers services in an outpatient setting, not inpatient or facility-based care.
What’s the difference between individual and family OOP max?
Individual applies to one member; family applies across all covered members.
What’s the difference between deductible and out-of-pocket max?
Deductible is what the client pays before insurance kicks in; OOP max is the total they’ll pay in a year.
What is an EOB?
An Explanation of Benefits — shows what was billed, covered, and owed.