GLOSSARY OF COMMON INSURANCE TERMS
The allowed amount is the amount your insurance carrier is willing to pay for a rendered service. This can be from a sampled average of charges for the service, derived from a fee schedule, an amount that other providers have agreed to accept for the same service, or the rates used by Medicare for the service. These vary from Payor to Payor and are not always consistent with the rates we are quoted during the eligibility process. Differences between this amount and billed charges can result in balance bills if we are not in-network with the Insurance. Not to worry! If this happens to you, your Patient Advocate will be there to help you navigate the processes to fix it.
A request for your health insurance company or the Health Insurance Marketplace to review a decision that denies a benefit or payment. It is also used to appeal underpayments. Most insurers allow appeals from both providers and Member appeals. Some payors may require a Designation of Representation form signed by the member before Apollo is allowed to appeal. A form provided by the Insurance company is usually required with these requests.
Allows provider to bill, appeal, and act as your representative to secure payment from your insurance.
A type of insurance that is attached to car insurance and pays for physical harm in the event of an accident. This does not cover medical expenses for the driver, but it does cover medical expenses for passengers and the other driver who was hit.
A request for payment that you or your health care provider submits to your health insurer when you get items or services you think are covered.
A form of medical cost sharing in a health insurance plan that requires an insured person to pay a stated percentage of medical expenses after the deductible amount, if any, was paid.
This is a form sometimes required by your Insurance before the processing of a claim. The primary intentions of coordination of benefits are to make sure that individuals who receive coverage from two or more plans will receive their complete benefit entitlement and to prevent benefits from being duplicated when an individual has more than one policy in place. This process covers insurance pertaining to several sectors including health insurance, car insurance, retirement benefits, workers compensation, and others. If you have been asked to provide this, your claim may not be processed without it. Please call your Patient Advocate for assistance.
A form of medical cost-sharing in a health insurance plan that requires an insured person to pay a fixed dollar amount when a medical service is received. The insured is responsible for the rest of the reimbursement.
A fixed dollar amount during the benefit period, usually a year, that an insured person pays before the insurer starts to make payments for covered medical services. Plans may have both individual and family deductibles.
Regulates insurers and other companies that conduct insurance business and assists insurance consumers. Each state has its own. This is a state regulatory body and complaints can be filed against Insurance plans. These typically apply to Fully Funded insurance plans. Please call your Patient Advocate, they can educate and assist you with this.
When the insurance states they will not process your claim, will not pay the claim, or underpays the claim. Contact your Patient Advocate for the tools and steps to help us overturn this with you.
Allows you to designate an individual to represent you on a specific appealed claim.
Your contract with the insurance company that explains your policy coverage in detail. These are extremely important when attempting to overturn a payment or coverage decision by your Insurance. Most of the time they can be accessed online by logging into your member portal on the Insurance Website.
A statement sent by your health insurance company to covered individuals explaining what services were paid for on their behalf.
This is a state-mandated option to assure that a person covered by a health benefit plan has the opportunity for an independent review of an insurance company’s determination for a service for which the individual filed a benefits claim that did not meet an insurance company’s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness and that as a result, the requested payment for the service was denied, reduced, or terminated by the insurance company. These are preceded by the normal Insurance company appeal processes.
A fully funded plan is a health plan that is sponsored by an insurance company rather than an employer. That means a health insurance carrier holds your insurance policy and assumes all of the risk. Your employer simply pays the premiums for your group coverage. Health Marketplace Exchange Individual policies fall into this category as well.
Explains how your medical information can be used or disclosed and how you can get access to this information.
If you have an insurance plan that originates in a specific region or state, and you receive covered services from a medical provider in a different location, the claim will be filed in the state the service occurred. The insurance where we filed the claim is referred to as the “local”, and the state the policy is originating from is referred to as the “Home Plan”. This is primarily a designation that applies to Blue Cross and Blue Shield franchises across the different states.
Used to provide all insurance information to the provider.
If you have an insurance plan that originates in a specific region or state, and you receive covered services from a medical provider in a different location, the claim will be filed in the state the service occurred. The insurance where we filed the claim is referred to as the “local”, and the state the policy actually originating from is referred to as the “Home Plan”. This is primarily a designation that applies to Blue Cross and Blue Shield Franchises across the different states.
The records that we create and retain in relation to your transport with us. These are given to the Insurance company when a claim is filed by us.
This is the criteria set in place by insurance guidelines and the Centers for Medicare and Medicaid Services to determine if a service is needed by clinical definition and diagnosis code. If a reviewer believes the patient could have been transported by a ground ambulance or did not need the service based upon the clinical documentation, they may deny the claim. If this happens, we will follow the procedures to appeal. If this happens with your claim, please contact your Patient Advocate and we will do everything possible to help you overturn it.
Refers to medical payment coverage, optional insurance coverage that is offered as a part of your auto insurance policy.
The most a health insurance policyholder will pay each year for covered healthcare expenses. It is also called the out-of-pocket limit.
Personal injury protection (PIP), also known as “no-fault insurance,” is a component of an automobile insurance plan that covers the healthcare expenses associated with a car accident. PIP covers medical expenses for both injured policyholders and passengers, even if some don’t have health insurance.
Your contract with the Insurance company that explains your policy coverage in detail. These are extremely important when attempting to overturn a payment or coverage decision by your Insurance. Most of the time they can be accessed online by logging into your member portal on the Insurance Website.
Unique number used to retrieve your account information. It is important to record these, as the Insurance company can look at previous conversations you have had with their representatives. These can be helpful to provide to Apollo when they are advocating for you.
The employer assumes the financial risk for providing health care benefits to its employees. In practical terms, Self-Insured employers pay for claims out-of-pocket as they are presented instead of paying a pre-determined premium to an insurance carrier for a Fully Insured plan.
An underpayment by the insurance company, which is smaller than the amount quoted during the Eligibility Process.
Also known as re-insurance. This is an insurance product for self-funded plans that protects against catastrophic or unpredictable losses. It is purchased by employers who have decided to self-fund their employee benefit plans but do not want to assume 100% of the liability for losses arising from the plans. Under a stop-loss policy, the re-insurance company becomes liable for losses that exceed certain limits called deductibles.
Refers to insurance that provides protection against liability caused by accidental injury or death of other persons. Examples of liability insurance are homeowner’s insurance, uninsured and underinsured motorist insurance, bodily injury protection, casualty and umbrella policies, wrongful death benefits, or professional liability.
A provision commonly found in the United States automobile insurance policies that provide for a driver to receive damages for any injury he or she receives from an uninsured, negligent driver.