percentage the patient is responsible for on a given insurance claim.
For example, a health plan would pay 80% of the allowed amount on a
claim, the 20% balance is the co-insurance amount to be paid by the
patient to the medical provider.
set dollar amount which must be satisfied within a specific time frame
before the health plan begins making payments on claims. For
example, if a plan has a $500 deductible, the patient must satisfy and
pay this amount to the medical provider before the health plan begins to
make any payment on a claim.
||When a brand name drug's
patent ends, other drug companies are able to make and sell duplicates
of the original drug. These Generic Drugs are often cheaper than
its Brand Name counterpart. Health Plans usually offer incentives
to its members in selecting Generic Drugs.
||Medical providers that
are part of a health plan's network and who have negotiated a set fee
and discount to see members of that particular plan. Health Plans
usually offer incentives to its members who see physicians within their
network and may actually not pay on a claim if they don't see a
physician in the network.
||An amount that an member
must pay up to before the health plan pays 100% of the allowed amount.
||A physician or medical
provider who serves as a "gate keeper" to the member's
health plan and health care system. Often, if a member has an HMO
or other restrictive type of plan, the Primary Care Physician must first
authorize a referral to a specialist for the service to be
covered. Many health plans also require that their members select
a PCP as part of their coverage.
||Also known as Usual and
Reasonable Fees. This is a cost containment measure used by health
plans to limit the amount paid to medical providers. All health
plans have different fees based on internal statistics of what the
health plan considers is a fair and reasonable rate for a specific
medical service or treatment.
||A method by the health
plan to mandate that a medical provider and/or patient contact the
health plan before a certain medical service or treatment is
performed. A reviewer at the insurance company, usually a health
care nurse, reviews the case and approves or denies the requested item