Allowed Amount: Amount that a medical plan agrees is reasonable for a service or procedure. If the charge is greater than that amount, the plan does not have to pay it.
Coinsurance: Your share of the costs for a healthcare service, which is typically calculated as a percentage of the allowed amount for the service. When you meet your deductible, you may have to pay coinsurance until you reach your out-of-pocket maximum. For example, if the plan deductible is $500 and your coinsurance is 15%, then you pay the first $500 of charges to meet your deductible. After your deductible is met, you would pay 15% in coinsurance and your plan would pay the remaining 85%.
Copay: The fixed amount you pay for a healthcare service, usually due at the time of service.
Deductible: Amount you pay for healthcare services before your health plan begins to pay. If your deductible is $500, for example, then you pay 100% of your healthcare charges until the amount you paid reaches $500. (Note: Copays do not count toward your deductible, and the deductible does not apply to preventive services, which are provided free.)
Discounted Amount: Amount deducted from the total charge on a medical bill. The discounted amount is a pre-negotiated, agreed-upon amount. Neither SmartHealth nor the covered member is responsible for the discounted amount. This amount is listed on your EOB. (See Explanation of Benefits listing for a definition.)
Excluded Services: Healthcare services not paid for or covered by your health plan. For example, the SmartHealth plans do not cover cosmetic surgery.
Explanation of Benefits (EOB): Statement sent from SmartHealth (or a health insurance provider) that lists the services received and the amount paid for by the health plan and the amount for which the member is responsible. EOBs generally list patient, provider, date of service, claim number, total charge, discounted amount, ineligible amount, amount the plan pays and the amount owed by the member.
Ineligible Amount: Amount not covered by the plan – it is considered outside of the allowed amount.
Out-of-Pocket Maximum: The most you pay during a plan year before your medical plan starts to pay 100% for covered benefits. Your deductible, coinsurance and copays count toward your out-of-pocket maximum. Premiums or charges for healthcare services your plan doesn’t cover do not apply toward the maximum.
Pre-Certification/Pre-Authorization: Requirement that you check with the plan administrator before using a healthcare service, treatment plan, prescription drug or durable medical equipment so the plan can decide if it is medically necessary. The ordering physician must submit the SmartHealth Pre-Certification Form along with any supporting documentation prior to the scheduled date of service.
Premium: Periodic payment (bi-weekly payroll deduction) for coverage of medical benefits for a defined benefit period.
UCR (Usual, Customary and Reasonable) Charge: Amount paid for a medical service based on what providers in the area usually charge for the same or similar medical service. UCR may be used to determine the allowed amount.