To help you understand information related to your health insurance policy, we've gathered some basic terminology that may be helpful for you.
Allowed amount- The maximum dollar amount that is covered by an insurance company.
Balance Billing (sometimes called “surprise billing”)- Services rendered by a doctor or other health care provider can have out-of-pocket costs such as a copayment, coinsurance, and/or a deductible. If you see a provider or visit a health care facility that is not in your health plan’s network, you may have additional costs or have to pay the entire bill. For example, if the provider’s charge is $100 and the insurance allowed amount is $70, the provider may bill you for the remaining $30.
Benefits- The expenses covered by a period of time by the insurance health plan.
BIN- pharmacy utilizes this number to identify which insurance plan to process.
Claim- A formal request sent to the insurance company for service reimbursement.
Coinsurance- The percent of cost the individual shares with the insurance company. Example: The individual pays 30% after the deductible is met.
Copayment - Based on the insurance plan, a copayment is paid at the office visit. Example: $70 copay to be paid at the time of visit with the specialist.
Deductible - The year amount you pay for health care services before the insurance company starts to pay. Example: If the deductible is $500.00, this must be met before benefits are reimbursed by the insurance company.
Group Number- the insurance company identifier is used for processing the correct insurance details under the payer.
Healthcare Clearinghouse- Transmits various medical claims data to the insurance carriers.
Health Insurance Portability and Accountability Act (HIPAA)- The Health Insurance Portability and Accountability Act of 1996 is a federal law that is required with national standards to protect the privacy and security of patient information without notice or consent.
Identification Number (ID)- this number is important to provide for services at the doctor or pharmacy. Majority of the time, this number is below the name on the insurance card.
In-network (INN)- A provider or healthcare facility part of the benefits plan network. Example: A patient sees a provider affiliated with their benefits in-network plan. The patient is likely to pay less for services.
Medicaid- A government-sponsored health plan for those who qualify. Each state determines the eligibility.
Out-of-network (OON)- A provider or healthcare facility is outside of the benefits plan network. Example: A student goes to see a physician who is not listed as an in-network provider for their health policy. They will pay more out-of-pocket for the services rendered.
PCN- Identifies drug benefit processors to determine the type of benefits package. It is used for routing pharmacy transactions.
Third party billing/ Commercial Payer- Also known as private insurance is coverage that is not associated with government payers such as Medicaid or Medicare.
Click this link to see an example insurance card.