Insurance Terminology
This is the fixed amount a patient pays at the time of service, often listed on their insurance card.
This term describes the percentage a patient pays for services after the deductible has been met.
Copay
Coinsurance
The document Headway receives from the insurance carrier detailing the final processed appointments and payments.
ERA (Electronic Remittance Advice)
What is Non-Delegated Payer Credentialing?
The stage that can take 120 days or longer and involves carriers where Headway does not handle the bulk of the application process.
This is considered the Source of Truth (SOT) and should be your absolute first stop when verifying a client's benefits if no processed claims are available.
Insurance Portal
The internal ticket type that the client or provider does not see, and is used to communicate with the IA team about calling the carrier.
Side Conversation (or IA Call)
This is the amount a patient must pay out of pocket before their insurance starts covering services.
This is the maximum amount a patient will pay out of pocket for covered services in a plan year.
Deductible
Out-of-pocket maximum
The two specific dates of the month when providers are paid out for confirmed sessions.
The 15th and the last day of the month.
What is the provider’s personal NPI (National Provider Identifier) used for?
The two identifiers Headway uses, along with a state-specific Tax ID, to credential a provider.
The required action you must confirm about the provider before communicating any verified benefit details to a client or provider.
Confirming the provider is credentialed (with the client's carrier)
The internal tool (like portals or dashboards) that agents are strictly prohibited from mentioning or referencing in public replies to clients or providers.
Internal Tools: Confluence, Slack, etc.
This type of plan requires members to use doctors and providers within a specific network for coverage.
HMO (Health Maintenance Organization)
The specific plan type that offers the greatest flexibility, allowing clients to see any doctor or specialist without a referral.
PPO (Preferred Provider Organization)
The typical frequency, in years, for a provider to undergo Recredentialing to maintain their status.
What is 3 years?
The two key components of an insurance card that are most useful for identifying TPAs or carveouts and telling you who actually processes the claim.
The Claims Address or Payer ID (on the back of the card)
The action you should take in Atlas if the insurance policy on file is completely different from the client's current coverage (e.g., a new carrier or policy).
Replace Insurance
This is the document sent by insurance companies explaining what was billed, what they paid, and what the patient owes.
EOB (Explanation of Benefits)
The non-billable session type that lasts for 15 minutes or less, meant to help the client and provider decide if they want to continue.
Phone consultation
The mandatory status that a provider must possess in a state before they are even eligible to begin credentialing there.
Licensed
This is what happens to the benefits in Atlas after you submit a Manual Override (MO).
The benefits become frozen (and won't update automatically)
If a client has an upcoming appointment within 48 hours, this is the specific urgent action you must take when setting up an IA Call request.
Marking the Urgent field as "Yes"
This type of coordination is needed when a client has two active insurance plans, to determine which pays first.
Coordination of Benefits (COB)
This payment method, which excludes Medicare and Medicaid, is used when a client does not have insurance or their plan is terminated.
Private Pay
This is required to process a claim as In-Network: the provider must be credentialed with the client's specific one of these.
Insurance Carrier (or Payer)
The three required items the IA team will deny an IA Call request for if they are not either provided by the client or pulled from the portal and uploaded to Atlas.
Client's State of Residence, Insurance Carrier, and Insurance Card Photo (or Demographics/Required Fields)
A provider is licensed in Colorado and North Carolina. They complete their MSC intake form but forget to list their required documentation. The agent should first direct them to their PGA or refer to this resource.
State by State Playbook