Terms and Definitions
In-network or participating provider: The healthcare professional has a contract with your insurance company agreeing to a dollar amount for a service and adjusts the fee based on the contracted amount.
Out-of-network or non-contracted provider: The healthcare professional does not have a contract for services with the insurance company. There may be benefits available, however; the benefit is not determined until the claim is reviewed. Therefore, the insurance company is not able to provide the dollar amount for a service to an out of network provider.
HMO (Health Maintenance Organization) vs. PPO (Preferred Provider Organization) plans: With an HMO, you have benefits available only when you received services from an in-network or contracted provider. PPO plans allow benefits for both in and out-of-network providers. Occasionally, if receiving a service from an out-of-network provider or facility the benefit may be reduced but, there is still coverage of some dollar amount.
Deductible: The dollar amount that must be satisfied prior to the insurance plan making payment or reimbursement.
Co-Insurance: The percentage the member is responsible for covering after the deductible is met.
Reasonable and customary limits or allowed amounts for services: The arbitrary amount an insurance company sets as the fee for a particular product, procedure, or service. (For example: We will bill them the full fee for each service, your benefit or coverage/ payment will be based on the dollar amount they have chosen.)
Exclusions and limitations: There are times where an insurance plan or group will not provide any payment or allow any benefit for a particular diagnosis or service. Limitations are occasionally seen as a maximum amount an insurance company will allow or pay for a particular diagnosis or service. The limit can be either in the form of a dollar amount or percentage.
CPT (Current Procedural Terminology) code: The code or number that represents the service, procedure, or equipment being performed or provided on the claim form.
ICD 10 (International Classification of Diseases) – Diagnosis code: The code or number that represents why the service, procedure or equipment was done or provided.