What does the information on my Statement mean?
Click here for a sample statement outlining what the different areas of your statement mean.
What is a co-payment?
A fixed dollar amount that a patient pays for each appointment. The patient is responsible for presenting this dollar amount at the time of the appointment. Please note this amount may differ, depending on the type of service, for example, a patient may have a $25 co-pay with a general physician, a $50 co-pay with specialty physicians, and $100 co-pay for Urgent Care facilities.
What is co-insurance?
A percentage that a patient is responsible for after insurance pays for a bill. For example, if a patient has 20% coinsurance, the insurance company is responsible for 80% of the bill, and the patient is responsible for the remaining 20%. Please note this amount may differ, depending on the type of service and/or if the physician seen is in-network or out-of-network with the patient's particular plan.
What is a deductible?
Amount that a patient is held responsible for before insurance will pay any of the patient's bills. Example: Patient has a $200 deductible plan - insurance processes bills, lists patient responsible for $200 deductible. The clinic must collect this deductible from the patient, not the insurance company. Please note that the insurance company may indicate a patient has met their deductible once the full deductible amount has been applied to his/her bills. However, the patient is responsible for paying their deductible, so it is not truly satisfied until the patient makes payment the healthcare provider for the amount outlined on their EOB.
What does it mean if I have a spenddown?
The amount a patient has to pay in medical coverage before Medical Assistance will pay. This is similar to a deductible.
What is meant by Patient Responsibility?
The amount due from a patient after the insurance company has processed a claim. This can include co-payments, coinsurance and/or deductibles.
On my EOB (Explanation of Benefits) it lists allowed/contracted amount, what is this?
This is the amount that has been agreed upon between the payer and the clinic to accept to as payment for services. This amount varies by insurance.
Who is the Payer?
Group responsible for paying the bills related to a visit.
What is a Third Party Administrator (TPA), or Third Party Payer (TPP)?
This is the company that reviews the bills for the insurance company and determines coverage and benefits.
What is a PPO?
Preferred Provider Organization: A health care delivery system in which providers contract to offer medical services to benefit plan enrollees. Enrollees can usually see physicians either in or out of the PPO network, but have increased incentive to see provider's in-network due to lower coinsurance and deductibles.
What is a HMO?
Health Maintenance Organization: Insurance plan where the patient has a Primary Care Clinic responsible for coordinating all care. HMO plans require an insurance referral authorized by the Primary Care Clinic in order to get coverage for a visit or test.
What is an Identification Number or a Group Number?
Identification Number - Also known as Policy #, Insurance ID#, Insured #. Is the number on the card that identifies a specific individual. May be the subscriber's social security number.
Group Number - Also known as Plan #, Account #, Employer group #. Identifies the company or group an insurance plan is provided through.
What does it mean when they ask who the subscriber/insured is?
The person who is the primary carrier of the insurance.
What is a Primary Care Clinic?
The clinic chosen by or assigned to a patient to manage their care (HMO plans). This clinic is responsible for issuing referrals for specialty care and testing by providers other than themselves.
When do I need a referral or prior authorization?
Referral - A form filled out by the patient's primary care clinic, which is submitted to the insurance company that authorizes office visits or services/testing to be performed. Often needed for HMO plans.
Prior Authorization - Permission from an insurance company or TPA to perform testing/certain injections/lab work. Prior authorization must be obtained prior to the time of the testing/injection/lab work. If there is no preauthorization in a case when it was required, the patient may have either reduced benefits or no benefits at all and be held responsible for the bill.
The need for referrals and/or prior authorizations will depend on the patient's specific insurance plan and the service being performed. The patient is responsible for obtaining insurance referrals, and can request one by calling their primary care clinic. If you are not aware if your plan requires referrals, please contact the insurance company directly, this number should be listed on your insurance card.
What is COBRA Insurance?
The Consolidated Omnibus Reconciliation Act of 1995 - this is a law that allows individuals to continue coverage with an insurance plan for up to 18 months by paying their own insurance premiums.
What does Coordination of Benefits mean?
When a patient has 2 or more insurance plans, the secondary insurance coordinates payment with the primary in order to pay only the full amount of the outstanding bill. Insurance companies may periodically require a "coordination of benefits update" from the patient. COB verifications are sent via letters or phone calls from the insurance company and must be completed by the member or claims will not process and the patient will be liable for the balance.