The world of health insurance Is full of terms and acronyms that might have your brain buzzing. Knowing exactly what these terms mean can help you better control costs and make the most informed decisions for your health and wallet.

Let’s break down 10 common health insurance terms that you, as a healthcare consumer, should know!

 

1. Claim

A claim is a request for payment that you or your doctor submit to your health insurance company after you receive care. Read this article >> to follow the journey of a claim, from creation to resolution.

 

2. Copay

A copay is the fixed amount the patient pays for a covered healthcare service.

 

3. Coinsurance

The amount shared by you and your health plan for health costs, calculated as a percentage.

 

4. Deductible

A deductible is the amount of health costs you are responsible for before the health plan starts sharing costs.

 

5. Explanation of Benefits

An explanation of benefits, or EOB, is a statement from your health insurance plan describing what costs it will cover for medical care or products you’ve received.

 

6. In-Network Provider

An in-network provider is a healthcare provider in contract with your insurance to provide services to plan members at a pre-negotiated rate.

 

7. Out-of-pocket max

The out of pocket max is the most you will pay in a given year for all covered services. This is a combined total of deductible, coinsurance and copayments made for any one individual. Once the out of pocket max has been met, all covered services are covered with no additional cost share.

 

8. Premium

A premium is the amount an individual or employer pays each month for your health insurance or plan. You will learn of the amount you are responsible for at open enrollment each year depending on the plan you choose, and typically see that amount withdrawn from one monthly paycheck, or split between two bi-weekly paychecks.

 

9. Prior authorization or Pre authorization

Prior authorization means getting approval before you can get access to medicine or services. This is not always necessary, but you should call your health insurance company using the number on the back of your ID care before any surgery, diagnostic, lab or other service you are going to receive to ensure your insurance provider has agreed to cover the service.

 

10. Referral

A referral is a written order from your primary care provider for you to see a specialist or get certain health care services. Not all health plans require a referral, but if your plan does, ask your PCP or clinic for an electronic referral before you visit a specialist. Without this referral, you’ll likely pay more for your care or it may not be covered. If you don’t know if you need a referral, sign in to your health plan account or call the number on your ID card to find out. Your ID card may even say "Referrals Required."

 

Now that you have a better understanding of these 10 common terms, you are one step closer to being the best healthcare consumer you can be!

Health Clinics are an appropriate (and convenient!) level of care for symptoms such as:

• Chronic condition management
• Coughing or sore throat
• Ear pain
• Eye itching, pink eye, or styes
• Fever
• headache or nausea
• Sprains
• Rashes
• or you are in need of lab work

Clients can also visit our clinic for an annual flu shot!

Step 1: Showing Your Healthcare ID Card

Giving your personal and healthcare insurance information to your provider is the start to a healthcare claim. Always bring your Healthcare ID card with you to an appointment with your healthcare provider. 

Pro-Tip = it's always best to contact your Insurance Carrier before going to your appointment to make sure your Provider is In-Network and the services you are going in for are covered under your policy. 

Step 2: Insurance Verification

The second step to generating a claim is verifying your insurance. Verifying your insurance confirms that you have coverage for the care you are about to receive, states your policy benefits, and displays whether your insurance provider requires prior authorization for the intended healthcare services.

Step 3: Coding

During a patient’s visit, the healthcare provider will take notes that are sent to their staff for coding. These codes signify diagnosis, procedures, medications, and supplies administered as well as the reason why. Here are some examples of common medical codes:

• Current procedural terminology (CPT)
• Diagnosis-related group (DRG)
• Healthcare common procedure coding system (HCPCS)
• International classification of diseases (ICD-10)
• National drug code (NDC)

Step 4: Listing of Charges-Services

Before care providers submit their coded claim for evaluation, they will list the charges for their services based on their contracted rates with the insurance provider. 

Step 5: The Claim is Submitted

Once the healthcare provider has completed their claim, it is submitted to the insurance provider.

Step 6: Claim Evaluation

Once the insurance provider receives the claim, they evaluate the claim and determine:

1. The validity of the claim

2. How much of the claim charges they will cover

The insurance company will accept the claim and reimburse the charge if the patient has sufficient coverage and received any required prior authorization.

The insurance company can reject the claim if it does not meet formatting requirements, has a medical coding error, the patient does not have sufficient coverage or did not acquire necessary prior authorization.

Rejected medical claims can be resubmitted for payment once the errors have been corrected.

Step 7: Explanation of Benefits and Final Billing

Once the insurance provider determines their participation in the claim, an explanation of benefits followed by a final bill will be distributed to the patient for any additional payments needed. 

Some providers require or want you to pay an amount upfront. If you do, keep a receipt of any prepayment and make sure it is accounted for in the final billing. If you overpay, you may have to initiate reimbursement directly from the provider. They may keep that balance and apply it toward any future services. Do not make any payments until you receive your explanation of benefits back from your insurance carrier and match it up with what you are being billed from the provider.

Information Sources:

https://www.definitivehc.com/blog/medical-claims-101-what-you-need-to-know

Prepare Now and Confidently Act Later.

Before a medical emergency or need for quick care arises, get familiar with your care options and how to get there or contact them. You can start preparing by writing down the answers to the following questions:

• Who is my preferred healthcare provider?
• Is my family doctor or preferred care provider in-network?
• What are my telehealth options through my insurance plan?
• Where is the nearest in-network walk-in clinic?
• Where is the nearest in-network urgent care center?
• Where is the nearest in-network emergency care center?

Knowing the answers to these questions along with contact information for each will be greatly beneficial to you when your time in need arises. Post this information somewhere in your home where you can easily access it. 

Telehealth is quickly increasing in popularity and saves patients not only time, but also money. The estimated cost of a Telehealth or virtual doctor visit is $59 or less. Pick up your phone, tablet, or laptop and schedule a virtual, face-to-face chat with a Board-Certified Doctor when faced with coughing, eye or ear pain, a fever, headache, nausea, sore throat or similar mild symptoms. 

Health Care Clinics

If you would prefer an in-person visit over a virtual one, Health Care Clinics are appropriate options for the symptoms treated via Telehealth as well as bites and stings, cuts, sprains, strains, rashes, and lab work. A clinic visit will typically cost less than a visiting a doctor’s office, but possibly more than or similar to a virtual visit. 

Doctor Office Visits

You should make an appointment to see your family doctor or preferred care provider for annual physicals, diagnostics, and to discuss health concerns, especially those that are tied to a family medical history. With a consistent doctor, annual physical exams set an atmosphere for trust and open discussions about family medical history that will lead to personalized prevention plans.

Urgent Care

How is urgent care different from emergency care? Urgent care is the middle ground between your primary care provider and the emergency department, and visits are significantly less expensive than an emergency room visit, and less time consuming. Urgent care is an appropriate level of care for animal bites, stitches, and open wounds or infections.

Emergency Care

The Emergency Room is where one should be headed if an individual’s condition is life threatening: trouble breathing, choking, electric shock, spine injury, heavy bleeding, seizures, poisoning, or similar symptoms. Medical emergency Doctors will treat such patients at an estimated cost of ~$1,500.

Become familiar with these care options and take note of who to contact and where to go for care the next time you find yourself in need of medical attention.