|
Code
|
Display
|
Definition
|
|
allowed
|
Allowed |
The maximum amount a plan will pay for a covered health care service. May also be called "payment allowance", or "negotiated rate". |
|
coinsurance
|
Co-Insurance |
The amount the insured individual pays, as a set percentage of the cost of covered services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%. |
|
copay
|
CoPay |
A fixed amount ($20, for example) the insured individual pays for a covered health care service after the deductible is paid. |
|
deductible
|
Deductible |
The amount the insured individual pays for covered health care services before the insurance plan starts to pay. |
|
eligible
|
Eligible Amount |
Amount of the charge which is considered for adjudication. |
|
memberliability
|
Member Liability |
The amount of the member's liability. |
|
noncovered
|
Noncovered |
The portion of the cost of the service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract. |
|
out-of-pocket-maximum
|
Out-of-Pocket Maximum |
The most the insured individual has to pay for covered services in a plan year. After this amount is spent on deductibles, copayments, and coinsurance for in-network care and services, the health plan pays 100% of the costs of covered benefits. |
|
visit
|
Visit |
A medical visit means diagnostic, therapeutic, or consultative services provided to a client by a healthcare professional in an outpatient setting. |
|
penalty
|
Penalty |
Benefit penalty is an approach used by the insurance company to reduce their payment on a claim when the patient or medical provider does not satisfy the rules of the health plan. Benefit penalties may occur when a pre-authorization is not obtained, for example. |