BALANCE BILLING An out-of-network healthcare provider billing a patient for the difference between what the patient’s health insurance chooses to reimburse and what the provider chooses to charge. CO-INSURANCE The percentage of costs of a covered health care service you pay after you’ve paid your deductible.
PRE-AUTHORIZATION Prior review of a procedure and authorization by the insurance company to pay for scheduled services. PREFERRED PROVIDER A provider who has a contract with your health insurer or plan to provide services to you at a redetermined rate. Costs will be less when receiving services from Preferred Providers. PREMIUM The amount that must be paid for your health insurance or plan each month. This amount is shared by you and your employer. PRIMARY CARE PHYSICIAN A physician who directly provides or coordinates a range of health care services for a patient. PRIMARY CARE PROVIDER A physician, nurse practitioner, clinical nurse specialist, or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services. SPECIALIST A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions. UCR (USUAL, CUSTOMARY AND REASONABLE) The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical services. The UCR amount sometimes is used to determine the allowed amount. URGENT CARE Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.
CO-PAYMENT A fixed amount you pay for a covered health care service.
DEDUCTIBLE The amount you pay for covered health care services before your insurance plan starts to pay. EMERGENCY SERVICES A medical emergency is an acute injury or illness that poses an immediate risk to a person’s life or long-term health. FORMULARY A list of prescription drugs that are covered by your health insurance plan. The formulary is separated into cost levels called tiers, which affects how much you pay for each drug. Also known as a Prescription Drug List (PDL). NON-PREFERRED PROVIDER A provider who doesn't have a contract with your health insurer or plan to provide services to you. You'll pay more to see a non- preferred provider. OUT-OF-POCKET MAXIMUM The most you could pay during a plan year for your share of the costs of covered services. After you meet this limit the plan will pay 100% of the allowed amount.
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