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Billing & Insurance Terms Glossary

Helpful Billing/Insurance Terms

Coinsurance: Coinsurance is your share of the costs of a health care service. It's usually figured as a percentage of the amount we allow to be charged for services. You start paying coinsurance after you've paid your plan's deductible.

Deductible: A deductible is the amount you pay for health care services before your health insurance begins to pay.

Out of Pocket Max: The amount of expenses not reimbursed by insurance. Yearly or lifetime, this amount is the max that a patient has to pay before the insurance reimburses at 100%.

Copay: Copay is a fixed amount you pay for a health care service, usually when you receive the service. The amount can vary by the type of service. You may also have copay when you get a prescription filled.

Allowed Amount: The allowed amount reflects how much the insurer has decided to pay for the procedure or visit. Sometimes insurers will use the term “usual and customary charges” or another term in place of “allowed amount.”

Out of Network: An out-of-network provider is one not contracted with the health insurance plan.

In Network: An in-network provider is one contracted with the health insurance company to provide services to plan members for specific pre-negotiated rates.

Non-covered Service: Service provided that is not covered under an individual’s insurance plan.

EOB: EOB, or Explanation of Benefits, is a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf.

Charges: The amount that a healthcare provider bills for services rendered to a patient.

Guarantor: The individual financially responsible for paying the balance.

Order of Insurance Coverage: Coordination of benefits- Determines which insurance is primary, secondary, tertiary.

Diagnostic: Testing/Procedure due to specific symptoms or problem.

Preventative: Screening tests to detect early disease or risk factors for disease. No symptoms or problems identified. If symptoms are present at time of screening, testing becomes diagnostic.

HCAP: Hospital Care Assistance Program for Ohio residents.