3 Letter Abbreviation
the forms you received from your insurance company outline your plan coverage and your financial responsibility
Explanation of Benefits (EOB)
the fixed amount of each healthcare bill you must pay out-of-pocket; typically due at the time of the visit
Co-Pay
the amount of money an insurance company charges to provide coverage
Premium
a formal written contract of insurance
Policy
Is this provider/health system in the network?
If not, how much will the cost be?
If the cost is too much, how do I find an alternative in-network provider?
when two or more plans cover the same person, the ..... is used to determine which plan will pay
Coordination of Benefits (COB)
the percentage of the healthcare bill you must pay out-of-pocket (can count toward your deductible and can be $0 once you’ve met your deductible)
Co-Insurance
the request made to the insurance company (by you or the provider) for payment after a visit or incident that cost money
Claim
Some people have coverage under more than one health insurance, but one must always be designated as primary. Claims are submitted first to the primary insurance company, and afterward, any remaining balance is submitted to the secondary insurance company.
Primary and Secondary Insurance Coverage
Does my plan provide coverage for this service?
• Are there limitations or exclusions on the coverage (i.e., situations in which the insurance will not
cover due to location, fault, diagnosis, or timing)?
• Do I need a referral or pre-authorization before getting the service/care? (Referrals come from your
primary care provider.)
• Is there a limit to the number of visits?
• Are supplies given as part of the care coverage too?
a one-time signed contract established between the insurance company and an out-of-network provider giving care, allowing services to be covered
Single Case Agreement (SCA)
the protection against financial loss provided by an insurance contract
Coverage
the amount (of the covered health care services or damage/loss) that you’re responsible for before your insurance company pays the balance on the claim.
Deductible
services needed to diagnose or treat the illness, injury, condition, or symptoms you are making claims for that meet accepted standards of medicine
Medically Necessary
Is there a deductible I need to pay?
• Is it different for in-network and out-of-network providers?
• When does the deductible reset for the year?
a type of health plan that contracts with a network of participating providers. You pay less if you use providers in that network; providers outside of the network can be seen at an additional cost.
Preferred Provider Organization (PPO)
insurance policies may start in the fiscal (June to July) or calendar (January to December) year. It is important to know when your policy starts and ends so you are prepared for your deductible to reset.
Coverage Year
a decision by your health insurance plan that whatever service you are requesting is medically necessary; given before you receive care
Preauthorization or Prior Authorization (PA)
a written order from your primary care doctor for you to see a specialist or obtain other specialized medical services.
Referral
• Is my ...... plan different from my medical plan?
Prescription
• Is lab work (blood and urine tests) covered?