Patient Insurance Glossary of Terms
Benefit – The amount your plan will pay a health care provider, as stated in your policy, toward the cost of the procedure to be performed.
Bill/Invoice/Statement – The summary of your medical bill.
Claim – The form that the health care provider files with a health insurance company that details the services and procedures performed by the health care provider, on your behalf, and other pertinent data that is required by the health insurance company to receive payment.
Co-Payment or Co-Pay – The part of your medical bill you must pay each time you visit your health care provider. Physician office co-pays differ from hospital/ambulatory surgery center co-pays.
Co-Insurance – The part of your bill, often in addition to a co-pay, that you must pay. Co-insurance is usually a percentage of the total medical bill—for example insurance pays 80 percent, patient pays 20 percent.
Deductible – The amount you must pay for medical treatment before your health insurance company starts to pay—for example, $500 per individual or $1,500 per family. In most cases, a new deductible must be satisfied each calendar year.
In-network – The health care provider has a contract with the health insurance company to provide you with medical care. The health care provider will submit your medical bill directly to the health insurance company for payment. However, you may be responsible for a co-payment, deductible and/or co-insurance according to your health insurance company benefit plan.
Non-covered charges – Costs for medical treatment that your health insurance company does not pay. You may wish to determine if your treatment is covered by your health insurance policy before you are billed for these charges by your health care provider.
Out-of-network – The health care provider is not contracted with the health insurance company to provide you with medical treatment. You are responsible for the payment of the medical care. Your health care provider may agree to submit your medical bill directly to the payer for payment. However, you may be responsible for an increased co-payment, deductible, co-insurance and/or additional charges according to your insurance company benefit plan.
Pre-authorization or certification number – A number authorizing the health insurance company to pay benefits for your care. You may need to obtain an approval number from your health insurance representative before you see your health care provider in order for the health insurance company to pay for your medical treatment. Your health care provider might be able to help you obtain the approval from the health insurance company.
Primary health insurance company – The health insurance company that is responsible to pay your benefits first when you have more than one health insurance plan.
Secondary health insurance company – The secondary health insurance company is not the first payer of your claims. The remaining claim balance will be sent to a secondary health insurance company, if provided, after payment is received by the primary health insurance company.
Advanced beneficiary notice (ABN) – If Medicare will not pay for a procedure, the health care provider will request you to review and sign an Advanced beneficiary notice. This notice will assist you in determining whether you wish to have the procedure performed and how you prefer to pay for it.