A request for your health plan to review a decision or a grievance.
When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.
Centers of Excellence (COE)
A center of excellence is a research and managed care facility focused on promoting best practices relating to a certain health care condition or topic. Each health plan identifies what constitutes expert, cost efficient and best outcomes for their programs. In some cases, using a center of excellence facility could be at no cost to you.
Your share of the costs of a covered health care service, calculated at 20% percent of the allowed amount for the service. You pay co-insurance after your deductible is met.
A fixed amount for a covered primary care, specialty, and/or urgent care visit.
The amount you owe for health care services your health plan covers before your health plan begins to pay on your behalf.
Your dependents are the eligible family members you can cover under certain benefit programs. Example: Legal Spouse and/or children up to the age of 26.
Employee Retirement Income Security Act of 1974 (ERISA)
A federally regulated standard of conduct for plan managers and fiduciaries created to protect the interests of employee benefit plan participants and their beneficiaries by providing plan information and enforcing provisions to ensure health plan funds are protected and that qualifying participants receive their benefits.
Explanation of Benefits (EOB)
A statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf.
Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
Anyone that is covered under the health benefit plan – employee, spouse and/or child(ren).
The most you pay during a benefit plan year (January-December) before your health plan begins to pay 100% of the allowed amount after your deductible is met. This limit never includes your premium or balance-billed charges. Your copays are included in your out-of-pocket max.
A decision by your health plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency.
The cost you and your employer share for your health plan paid through your paycheck.
Summary of Benefits and Coverage (SBC)
A short, plain-language summary of your health plan benefits.
Summary Plan Description (SPD)
An ERISA required document with the key function of communicating health plan rights and obligations to participants.
The remote diagnosis and treatment of patients by means of telecommunications technology.
Third-Party Administrator (TPA)
An organization that processes insurance claims or certain aspects of employee benefit plans such as its claims processing, provider networks, utilization review, or membership functions.
Transparent Open Network
Allows for transparency in pricing for medical services (no hidden costs). Members are not tied to a pre-defined network of doctors or facilities; instead, you are able to use any provider or facility that accepts the medical benefit plan.