Confusing Health Care Jargon—Simplified!
What are covered services?
Covered services include medical services that are payable under your health care plan.
What are non-covered services (exclusions)?
Medical services that are not payable under your medical plan. You will be responsible for the full cost, and they won't apply to your deductible or out-of-pocket maximum.
What is a balance bill?
A balance bill occurs when a provider or hospital receives the fair and reasonable payment from your insurance but seeks to collect additional amounts directly from you. The "balance" sought to be collected against you will match the "discount" determined by your plan as reflected on the Explanation of Benefits (EOB) you receive from your plan administrator. You are only responsible for the patient responsibility amount as shown on your EOB. If you receive a balance bill, please call a ClaimDOC Member Advocate for assistance.
What is a copay?
Copayment is the amount you pay at the time of service. This is a predetermined dollar amount, not based on a percentage. This could be for office visits, urgent cares, lab work and emergency room visits. You may be required to pay this on the day you visit the doctor, or they may send you a bill for it.
What is a deductible?
The deductible is the amount you pay before your insurance plan begins sharing costs. The portion of the deductible you are responsible for each visit will be calculated after the provider submits your medical claim.
What is a provider?
Generally, this term includes doctors, physicians, nurses, nurse practitioners, counselors, therapists, and other medical professionals.
What is a reduction?
When ClaimDOC receives the bill from your doctor or hospital visit, we audit this and “reduce” it to reflect a “fair and reasonable” reimbursement. The reduction is the amount by which we lower the bill to reflect the corrected amount.
What is an Explanation of Benefits (EOB)?
An EOB is the statement you receive from the plan administrator after your claim is processed. This is not a bill. The EOB describes how your claim was processed and how your benefits were applied. This document will also provide you with the amount of money you may owe the medical provider if applicable.
What is an out-of-pocket maximum?
This is the most you will pay during the plan year.
What is coinsurance?
Coinsurance is the percentage of you pay for the medical charges, after meeting your deductible. The rest is paid by your health plan. For example, if your plan has an 80/20 level, your plan will pay 80% of the bill, and you are responsible for 20% until you reach your out-of-pocket maximum.
What is the allowable?
The allowable is the amount your plan determined as the fair and reasonable reimbursement for the medical services you received. This may be a combination of plan payment and patient responsibility.