Julia Peterson | Jun 19, 2018
Wading through a 20-page-deep policy can be a difficult task, but it becomes easier when you know what you’re reading.
This is the amount of money you have to pay before your insurance starts to pay. In many cases, your deductible will come out of your first claim. You’ll be responsible for that amount, and then the insurance pays whatever is left over (after coinsurance if there is any — see below for more on that). Check your plan to see if you have a deductible that only applies once during your coverage period or one that applies for each new illness or injury. This way you’ll know what to expect for your out-of-pocket expenses.
This is the amount of money you pay for each visit, upfront at the doctor’s office or for a prescription. Most Seven Corners plans do not have copays, but if yours does, this means you must pay this amount at the visit, then insurance pays the rest (after any applicable deductible). Copays typically do not count toward the deductible.
Coinsurance is a percentage of costs that you’re responsible for, and a percentage that the insurance company will pay for eligible benefits. For a lot of plans, you’ll see 80/20 coinsurance. This means that the insurance company pays 80 percent of the bill, and you pay the remaining 20 percent. Coinsurance is applied after any copay and deductible are taken out. If your plan doesn’t mention any coinsurance, it means that the plan pays 100% after you pay your deductible and copays.
Benefits are any services or expenses that are covered by your insurance. Keep in mind, though, that just because it’s listed as a benefit doesn’t mean it’s covered. There could be an exclusion that applies, too. It’s a good idea to be familiar with all the benefits and exclusions in your policy, so that you aren’t surprised if a claim is denied because it wasn’t a covered benefit.
Occurrence, incident, illness – these are all ways to refer to a group of related claims. All your claims will be grouped by illness or occurrence, so that they are handled all together. This makes it easy on all of us to keep the claims organized.
6. Medical Records.
Sometimes, to determine if a claim is covered and does not fall under any exclusions, we request medical records. Medical records are detailed reports from your doctor visits. Usually, you are not given all your records unless you request these. To be sure that your claim is reviewed in full, sometimes we need these extra details.
Provider, or service provider, is a fancy word for a medical doctor, facility, or company that provides medical services. Any time you see the word provider, it refers to that clinic or doctor you visited.
8. PPO/Provider Network.
Now that you know what a provider is, this phrase may make more sense. A Preferred Provider Organization (PPO) or Provider Network is a group of providers that are contracted with us. Many Seven Corners plans use UnitedHealthcare PPO. Providers you find within this network will accept the insurance and bill us directly if your plan uses this PPO. Some plans have no provider network. Check your plan or give us a call, if you’re not sure.
This is a term for bills you send to us that you would like reimbursement for (or that you’d like us to pay to your medical provider). You or your provider may file a claim for any service you receive, and we’ll review that claim and let you know what is payable.
An appeal is a way for you to dispute a denial of a claim. When we deny a claim, and you believe there is information (details we have not already reviewed) that would help prove it is payable, you can file an appeal. This is simply a letter explaining why the claim should be paid and some type of supporting document, perhaps from a provider, that supports the appeal. Think of it as a second chance for your claim.
Now you understand a few more insurance terms! There are plenty more to be found in a plan, so if you have any questions, feel free to reach out to us, and we’ll be happy to help!
About the Author
Julia Peterson joined the Seven Corners Customer Service team in February 2016. She is known as a writer and photographer, an extrovert, and master of the Rubik’s cube. She works from home in Michigan where she lives with her husband and her orange, half-blind cat, Murphy.