| A | B |
|---|
| copayment | member responsibility, a fixed amount (E.g. $25, $35,$45) usually for an office visit or urgent care visit |
| deductible | member responsibility, a set amount that would have to be paid each policy year before certain benefits will be paid by the plan |
| co-insurance | member responsibility, a percentage amount (E.g. 20%) |
| maximum out of pocket | a set amount per policy year, once met, coverage will typically go to 100% of the AA for eligible services |
| mamimum benefit | a set amount that PEHP will pay out per policy year for a specific benefit, such as $1500 in orthodontia |
| dependent | a person eligible on the plan other that the primary insured, such as a spouse or child |
| primary insured | the person eligible to have insurance coverage through their employer |
| pre-authorization | prior to services, provider supplies documentation showing the medical necessity of the procedure, equipment etc. |
| pre-determination | Dental only - a treatment plan submitted prior to rendering services to determine how the claim will be processed. Also referred to as pre-authorization |
| cob | when a person(s) is covered by more than 1 insurance company. We will coordinate benefits amongst the companies invovled. |
| contracted | a provider that has signed a contract with PEHP agreeing to accept our allowed amounts (AA) and not balance bill the member. |
| Non-Contracted | a provider that has NOT signed a contract with PEHP and does not have to accept our allowed amount (AA) as payment in full and CAN balance bill the member. |
| swing | having both In Network and Out-of-Network benefits. |
| timely filing | a period of time that PEHP allows claim submission in order to be eligible for payment. |
