Insurance Review

Allowable Charge

the maximum amount, according to the individual policy, that insurance will pay for each procedure or service performed

Beneficiary

a person eligible to receive the benefits of a specific policy or program

Benefits

services that an insurer, government agency, health care plan offers to pay for an insured individual

Case management services

process in which the attending physician or agent coordinates the care given to a patient by other heath care providers

Claim

a form sent to an insurance company, requesting payment for covered medical expenses

Coinsurance

also referred to as copayment; insurer and insured slip the cost of health care at a specified percentage, 80/20 or 70/30

Copayment

provision in an insurance policy requiring the policyholder to pay a specified percentage of each medical claim

Customary fee

average fee charged for a specified service or procedure

Deductible

amount owed by insured on a yearly basis before the insurance company will begin paying for services

Explanation of Benefits (EOB)

insurance report accompanying all claim payments that explains how the insurance company processed a claim

UCR allowable charge

usual, customary, reasonable charge that represents the maximum amount an insurance company will pay for a given service based on geographical averages