Co-insurance is the amount you are required to pay for medical care in a fee-for-service plan after you have met your deductible. The coinsurance rate is usually expressed as a percentage and depends on your plan. For example, if the insurance company pays 80% of the claim, you pay 20%.
Contractual adjustments are the difference between what the doctor bills and what your insurance allows if your doctor is contracted with your carrier.
A fixed fee that subscribers to a medical plan must pay for their use of specific medical services covered by the plan.
The deductible refers to the amount of money that the insured would need to pay before any benefits from the health insurance policy can be used. This is usually a yearly amount so when the policy starts again, usually after a year, the deductible would be in effect again.
Explanation of Benefits
An Explanation of Benefits (EOB) is an itemized statement provided by your insurance company. It details what action your insurance company has taken on your claims. You should keep EOBs with your health insurance records for reference.
Primary and Secondary Insurance
Since many people have available medical insurance from more than one plan (such as two employed spouses covered under group health insurance plans), insurance companies do not want insureds to profit through their health insurance. To prevent double recovery, most health insurance plans have provisions which determine how primary versus secondary coverage will be determined. Primary coverage is provided through the plan of which they are a member (such as the spouses both covered through their respective employment – the primary coverage is provided under the plan provided by the employer of each spouse) or the plan under which the member has been a participant for the longest time period. Secondary coverage, usually as a result of being covered as a dependent under someone else’s health insurance plan, provides reimbursement for medical expenses after exhaustion of coverage available through the primary plan.
A current Procedural Terminology (CPT) code used by a physician or other provider to describe the procedure or service rendered to the patient.