Insurance terms

This is a health insurance company's system of approving the performance of medical services and/or the fulfillment of medical orders. An authorization is not a guarantee of payment.

An itemized bill submitted by a medical or durable medical equipment provider to the insurance company on behalf of the patient, customer and/or insured to pay for items or services that were administered by the healthcare provider.

If your insurance requires this, it is a percentage that you (the insured) pay after meeting your health insurance plan deductible. It is usually written as a pair of percentages with the health insurance's portion stated first (for example 80/20 or 70/30).

Generally, coinsurance applies to PPO (Preferred Provider Organization), POS (Point-Of-Service Plan), and EPO (Exclusive Provider Organization) plans.

if you have more than one health plan, a Coordination of benefits will determine the order each company will pay. If you receive insurance coverage through your employer, this plan functions as the primary while any other plan would be secondary (for example insurance obtained through the employment of a spouse). The primary insurance plan will pay their percentage for the claim, and the remainder will be billed to the secondary insurance. Having a secondary insurance plan does not guarantee that it will pay what the primary does not.

A copayment is a flat fee required by some insurance companies to pay for services like office visits, and pharmacy prescriptions. Copayment amount may change based on the service being provided and are usually are seen with Health Maintenance Organization plan types.

A medical provider that has an agreement with an insurance plan to accept their patients at a previously agreed upon rate of payment. The plan will pay a higher percentage of the claim when using a contracted provider compared to a provider that is not contracted.

These are services and/or items for which an insurance plan will pay. With regards to diabetes supplies, examples of items covered by health insurance include insulin pump, supplies needed to use the insulin pump, as well as other diabetes management supplies.

This is the date medical services were provided to you. For medical items received from Medtronic, it is the date the product is shipped.

The dollar amount your health insurance plan may require you to pay out-of-pocket each year before your insurance plan begins to make payments. Not all health insurance plans require a deductible. Generally, deductible applies to PPO (Preferred Provider Organization) plans.

This is a situation when an insurance plan will not pay a claim/service, procedure or prescription. This may be because you do not meet certain criteria, or the item is not covered by specific insurance policies.

This benefit provides coverage for medical equipment used for home healthcare. A prescription from a healthcare provider is required. The items covered under this benefit can vary by insurance plan but typical diabetes items include insulin pumps, and some diabetes management supplies.

An EPO insurance plan is a network of individual medical care providers, who have entered into written agreement with an insurer to provide health insurance to subscribers. EPOs are similar to HMOs as they require the subscriber to select a primary care physician or medical group who will be responsible for issuing referrals to specialists. You must stay within the network and use preferred providers to receive any reimbursement or benefit for medical care provided, except for some exceptions in cases of emergency. EPOs are also similar to PPOs as their benefits are similar but the provider panel from which an EPO member may obtain care is smaller than with a PPO.

This is a statement form your health insurance company, that provides details on recent medical care charges and benefits plan payments. It includes a summary of services provided, the amount paid by your plan to the provider, and your financial responsibility. It is important to note that Health Maintenance Organization) plans do not always provide an Explanation of Benefits.

Programs offered by some employers allow for employees to set aside pretax money from their paycheck, to pay for the employee’s share of insurance premiums or medical expenses that their insurance plan does not cover. Usually, this money must be used within the benefit year.

The maximum amount of money that the health insurance plan will pay for a specific medical service or procedure.

An HMO is a type of group health insurance plan where the medical needs are provided by a managed system of medical care. The system provides medical care through a group of doctors, medical personnel, and facilities that work directly for the HMO. The care is done at their clinics by their doctors. You are required to choose a primary care provider who will direct your medical needs through one of the system's clinics and obtain any authorizations necessary for the patient to receive specialty services. You must stay within the system in order to receive any reimbursement or benefit for medical care provided.

This is a type of health insurance that covers most serious medical expenses, such as hospitalization, up to a maximum limit, usually after a deductible and co-insurance has been met by the policyholder.

A network is a group of healthcare providers and hospitals that provide services to members of a particular health insurance company's plan. The network provides services at lower rates than usual.

These are services and/or items for which an insurance plan will not cover. Depending on your insurance company's response, as identified on your Explanation of Benefits, the member can be held financially responsible for items not covered. With regards to diabetes supplies, typical examples of items not covered by health insurance may include the Serter® auto-insertion devices or any accessories for your insulin pump (for example a pouch or case).

Some benefits packages identify a maximum on the yearly out of pocket expense paid for health related services. Depending on your health plan, these expenses may include an annual deductible, coinsurance, and copayments. Once your yearly maximum out of pocket expense has been reached, your health plan benefits can increase up to 100%. For more information please review your benefit package with your insurance carrier.

A payer or payor is a company that provides health insurance plans. Some examples of these are Blue Cross/Blue Shield and Medicare.

A PBM is a third party administrator of prescription drug programs. They are responsible for processing and paying prescription claims. Some insurance companies will classify your diabetes management supplies (reservoirs, infusion sets, sensors) as a pharmacy benefit rather than durable medical equipment.

A POS allows you to choose providers or specialists within the POS network referred by your primary care provider, or to self-refer to a provider outside the network. You will receive the highest level of benefits if you use providers inside the network. When you enroll in a POS insurance plan, you are required to choose a primary care provider who must be chosen from within the healthcare network and becomes your "point of service." If you choose to go outside the network, it becomes your responsibility to fill out forms, send bills in for payment, and keep an accurate account of healthcare receipts. With POS health insurance you have greater freedom, but at a higher cost.

A policyholder is the owner of an insurance policy; usually, but not always, the person who is insured.

A PPO is a organization of hospitals and healthcare providers who have contracted with an insurer or a third party administrator to provide healthcare. People who have PPOs have more flexibility to choose a primary care provider and to go to a specialist without first obtaining a referral. PPO members can also be reimbursed (either partially or fully) if they use a doctor that is not listed in the network, unlike EPO members. if you choose to see someone out of network the deductivle may be higher and the percentage that insurance pays may be lower.

Generally, you will have a yearly deductible to pay out of pocket, before the insurance company will start paying for medical services. You may also pay a copayment at the time of each medical service/office visit. The insurance company usually pays a percentage of the medical fees for the in-network doctor, with the insured being responsible for the remainder of the bill.

A referral is the recommendation of a healthcare provider. In HMO plans, a referral is usually necessary to see any specialist other than your primary care physician (PCP), if you want the service to be covered. The referral is obtained from your PCP, who may require an in office consult.

This is the total amount your health insurance plan requires you to pay towards the cost of your healthcare. Once you reach your maximum amount, your insurance plan will cover your expenses at 100%. For example: If your plan has an out-of-pocket of $2,500, once your payments have totaled $2,500 in a plan year, all other claims are paid at a 100%.