Insurance words should not hide the decision.
Search common coverage, billing, and appeal terms in plain language.
The plan-recognized amount used to calculate payment and cost sharing.
A request for a health plan or program to reconsider an adverse decision.
Billing a patient for the difference between a provider charge and the amount paid or allowed, when permitted.
A request for payment submitted to a health plan after a service or item.
A percentage of the allowed amount that a member may owe.
A fixed amount a member may owe for a covered service or prescription.
An amount a member may need to pay before plan cost sharing begins for certain services.
A decision not to cover or pay for a requested service, item, medication, or claim.
Explanation of Benefits; a statement showing how a plan processed a claim. It is usually not itself a bill.
A detailed document explaining a plan's benefits, exclusions, costs, and procedures.
Independent review of certain plan denials after required internal steps.
A health plan's list of covered prescription drugs and related rules.
An advance estimate that uninsured or self-pay patients can often request for scheduled care.
A complaint about a plan, service, access issue, or quality matter; definitions vary.
A plan model that commonly emphasizes network care and primary-care coordination.
A provider or facility contracted with the specific health plan.
Private Medicare Supplement insurance designed to cover certain Original Medicare cost sharing.
The clinicians, facilities, pharmacies, and suppliers contracted with a plan.
The annual limit on certain covered, in-network cost sharing; premiums and many other charges may not count.
The regular payment required to maintain coverage.
Advance plan review required for certain services, medications, or items.
A plan model that commonly permits out-of-network use at higher cost.
A direction or authorization from one clinician, often primary care, to another provider.
A limited enrollment window triggered by qualifying circumstances.
A standardized overview designed to help consumers compare health plans.
A faster review pathway that may apply when delay could seriously jeopardize health or recovery.