Beneficiary / Insured - someone who is eligible to receive benefits under an insurance policy or plan.
Beneficiary / Insured Liability - the amount beneficiaries must pay for covered services. These include co-payments, coinsurance, deductibles and balance billing amounts.
Co-insurance - a type of cost sharing where the beneficiary / insured and insurance provider share payment of the approved charge for covered services in a specified ratio after payment of the deductible by the insured. For example, for Medicare physicians' services, the beneficiary pays co-insurance of 20 percent of allowed charges.
Coordination of Benefits (COB) - a provision in healthcare that determines the insurances’ and patient’s share of the expenses.
Co-payment – (1) A fixed dollar amount paid for a covered service by a beneficiary / insured (See Co-insurance and Deductible). (2) Amount that a member of a health plan has to pay for specific health services, such as visits to a physician. (See "Beneficiary Liability" and Co-insurance”)
Date Of Service (DOS) – the date(s) healthcare services were provided
Deductible – The amount of eligible expense a beneficiary / insured person must pay each year out of pocket before the plan will make payment for eligible benefits.
Explanation of Benefits (EOB) – the insurance company’s statement that lists services rendered, amount billed and payment made. This normally would include any amounts due from the patient such as "Beneficiary Liability," "Co-insurance," "Deductible" and or "Co-payment" amount.
Health Insurance – coverage that provides for the payment of benefits as a result of sickness or injury. Includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment.
Health Maintenance Organization (HMO) - an entity that provides, offers or arranges for coverage of designated health services needed by plan members for a fixed, prepaid premium.
Medicaid / AHCCCS – A state/federal benefit program for the poor who are aged, blind, disabled or members of families with dependent children. Each state sets its own eligibility standards. Only 40 percent of individuals with income below the poverty level currently are covered.
Medicare – A federal health benefit program for people over 65 and disabled that covers 35 million Americans.
Out of Network (OON) – coverage for services obtained from a non-participating provider. Typically, it requires payment of a deductible and higher co-payments and co-insurance than for treatment from a participating provider.
Part A Medicare – Medicare Part A (Hospital Insurance) helps cover your inpatient care in hospitals, critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. You must meet certain conditions.
Part B Medicare – Medicare Part B (Medical Insurance) helps cover your doctors’ services and outpatient hospital care. It also covers some other medical services that Part A doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.
Primary Care Physician (PCP) – a physician, the majority of whose practice usually is devoted to internal medicine, family/general practice and pediatrics. An obstetrician/gynecologist sometimes is considered a primary care physician, depending on coverage.