This glossary defines many of the common terms used in connection with third party payers. The definitions for terms in boldface print can be found in alphabetical order.
Benefits are medical services and supplies that government or private insurance pays for. Benefits may cover part or all of a particular treatment, and often have restrictions.
Claim — is a request for payment from a commercial or government health insurance plan. A claim may be submitted by a healthcare provider, such as a clinic, or by an individual.
Coinsurance — refers to a percentage of fees that are the client’s responsibility, after the deductible is met. For example, an insurance policy may cover only 80% of medical fees, leaving the other 20% for the client to pay. Coinsurance can be found on the Eligibility, Coverage, or Benefit Report.
Commercial Health Insurance — sometimes referred to as Private Insurance is health coverage provided by a non-government company, such as Aetna or Blue Cross/Blue Shield. Part or all of the cost of commercial insurance may be paid by an employer. Some commercial insurance is subsidized by the government under the Affordable Care Act. Individuals may also purchase commercial health insurance privately.
Copay — is the dollar amount that a client must pay at each visit, normally a set fee. A typical Copay might be $10.00. The Copay can be found on the Eligibility, Coverage, or Benefit Report.
Current Deductible is the amount of deductible remaining for a calendar year. If a client has already paid $400.00 of a $1000.00 deductible, the Current Deductible would be $600.00. The Current Deductible amount can be found on the Eligibility, Coverage, or Benefit Report.
Deductible — is the amount a person must pay out of his own funds each calendar year for medical services before insurance will start to pay benefits. For example, a Deductible might be $1000.00 per year.for an individual or $2500 per year for a family.
Eligibility, Coverage, or Benefit Report — is a report, usually electronic, generated as a response to a Real Time Electronic Eligibility Check or Manual Eligibility Check. It is used to verify that a client does have current coverage for treatment. The Eligibility, Coverage, or Benefit Report supplies information about the Current Deductible, Co-pays and Co-insurance.
Medicaid — is a health insurance program for people who do not have the income or resources to pay for their own medical care. It is funded by the government.
Medicare — is a medical insurance program, funded by the United States federal government, for persons ages 65 or older and some younger people with disabilities. Medicare does not cover the cost of Methadone Maintenance Treatment (MMT).
Out-of-Pocket — is some or all medical cost that patient pay for themselves. It is sometimes referred to as Self-Pay.
Plan Deductible — is the amount a person must pay out of his own funds each calendar year for medical services before insurance will start to pay benefits. For example, a Plan Deductible might be $1000.00 per year.for an individual or $2500 per year for a family. Deductibles will be indicated on the Insurance ID card as an annual amount.
Primary Payer — is the health insurance plan that covers the patient as an employee, subscriber or member.
Private Health Insurance — sometimes referred to as Commercial Health Insurance is health coverage provided by a non-government company, such as Aetna or Blue Cross/Blue Shield. Part or all of the cost of private insurance may be paid by an employer. Some private insurance is subsidized by the government under the Affordable Care Act. Individuals may also purchase private health insurance themselves.
Secondary Payer — is the additional health insurance plan that covers the patient in addition to his or her primary plan.
Self-pay — is some or all medical costs that patients pay for themselves. It is sometimes referred to as Out-of Pocket expenses.
Third Party Payer — is a government agency or commercial insurance company that pays some or all of a covered persons surgical and medical expenses
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