| A | B |
|---|
| Effective Date | The date your insurance is to actually begin. You are not covered until the policies effective date. |
| Termination Date | The date your insurance is no longer active You are no longer are covered by your insurance. |
| Deductible | The amount an individual must pay for health care expenses before insurance (or a self-insured company) covers the costs. Often, insurance plans are based on yearly deductible amounts |
| Out- Of- Pocket Max | A predetermined limited amount of money that an individual must pay out of their own savings, before an insurance company or (self-insured employer) will pay 100 percent for an individual's health care expenses |
| Co- insurance | Refers to money that an individual is required to pay for services, after a deductible has been paid |
| Co-pay | A predetermined (flat) fee that an individual pays for health care services, in addition to what the insurance covers. |
| Lifetime Max | The maximum amount a health plan will pay in benefits to an insured individual during that individual's lifetime. ( policy life) |
| Pre- existing | A medical condition that is excluded from coverage by an insurance company, because the condition was believed to exist prior to the individual obtaining a policy from the particular insurance company |
| Exclusions | Medical services that are not covered by an individual's insurance policy |
| Limitations | a limit on the amount of benefits paid out for a particular covered expense, as disclosed on the Certificate of Insurance |
| Pre- Determination | This prrocess allows the HCP to send the insurance company a statement listing a proposed services or treatment for a specific patient |
| Prior Authorization | The process of obtaining authorization prior to the member receiving services |
| Capitation | This means the doctor agrees to be paid a set amount by payer for treating a patient based upon specific service type or overall treatment |
| Benefit Investigation | The process of verifying patient eligibility, benefits, and coverage for a drug or service rendered |
| Benefit Summary | Is a Fax summary( out put) sent to HCP to inform of a specific patients benefits and coverage for drug or service rendered |
