Healthcare providers or facilities that do not have a contractual agreement with an individual’s insurance plan. Seeking services from these providers may result in additional costs.
A cost-sharing arrangement in health insurance where the policyholder pays a percentage of the covered healthcare expenses after meeting the deductible.
The amount an individual must pay for covered healthcare services before the insurance plan begins to contribute.
The maximum amount an individual has to pay for covered healthcare services during a specific period, after which the insurance plan covers 100% of the costs.
When a healthcare provider bills a patient for the difference between the provider’s charge and the allowed amount covered by the insurance, often applicable with out-of-network services.
The maximum amount an insurance plan is willing to pay for a covered healthcare service, based on negotiated rates with in-network providers.
The average cost of a healthcare service in a specific geographic area, used by some insurance plans to determine the allowed amount for out-of-network services.
A list of healthcare providers, including doctors, hospitals, and clinics, that have agreed to provide services at negotiated rates with a specific insurance plan.
A statement from the insurance company explaining how a claim was processed, including details on what the insurance covered, what the patient owes, and any remaining balance.
A recommendation by a primary care physician for a patient to see a specialist or receive specific medical services.
The process of obtaining approval from an insurance company before receiving certain medical services, procedures, or medications.
Medical services required for the treatment of a medical condition that, if not treated immediately, could lead to serious harm or impairment, often covered by insurance regardless of network status.
The requirement for insurance plans to have an adequate number of in-network healthcare providers to ensure that covered services are accessible to plan members.
A formal request made by a policyholder to review and reconsider a decision made by their insurance company, such as a denied claim or coverage determination.
Unexpected bills that may arise when an insured individual inadvertently receives care from an out-of-network provider, often due to unforeseen circumstances during in-network treatment.