Insurance Glossary

Here you will find a list of terms used by Wee Care Pediatrics as well as your health insurance plan. Knowing these terms may help you better understand your insurance, billing practices or communications from your insurance company. Don’t worry, it’s confusing to all of us! If you have any additional questions about a term or how it works, give our office a call. We’ll be more than happy to explain what it is and how it works. The more knowledge you have the better you can protect yourself.

 

PCP– Primary Care Physician (applies to HMO’s as your assigned doctor)

HMO– Health Maintenance Organization (this plan DOES require a PCP as well as referrals)

PPO– Preferred Provider Organization (this plan does NOT require a PCP)

POS– Point Of Service (this plan is cool, you can use it as an HMO-less out of pocket cost but requires PCP and referral or PPO-more out of pocket cost but does not require PCP and the freedom of not needing a referral)

Primary Insurance– This term applies if you have double coverage; this plan would be billed first

Secondary Insurance– This plan would be billed second (keep in mind, secondary insurance does not always pick up all copays or deductibles billed from primary)

*Primary vs. Secondary concerning Medicaid* – In this scenario, when a patient has any commercial insurance plan and Medicaid, the commercial plan or “Private insurance” will always be your primary plan and your Medicaid plan will always be secondary. Medicaid will not reimburse any claims until your primary or commercial insurance is billed first. Medicaid will ask for payment back from your doctor if it finds there is a primary or commercial insurance that should have been billed first. The State of Nevada is very strict on this rule. Give us a call with your primary insurance information to avoid any delays on processing your claims.

Birthday Rule– “The Birthday Rule” determines what insurance plan is “Primary” when you have double coverage. The subscriber with the birthday that falls first in the year is primary and the subscriber with the birthday second in the year becomes “Secondary.” Despite popular belief, you cannot choose what plan is billed first. The Birthday Rule determines what plan is billed first unless there is a court order naming what insurance plan is to be billed first.

COB or Coordination of Benefits– Your insurance carrier is inquiring whether you have more than one insurance plan/coverage for your child. You must respond even if you don’t have other coverage! All billed claims will deny if you do not respond in time. This is typically done on an annual basis so be sure to respond, you will be held financially responsible by your insurance carrier and will be billed the full amount not reflecting your insurance discount. A simple call fixes it all!

Copay– A fixed amount you pay towards services provided by your doctor that is part of the whole payment allowed by your insurance plan. For instance, your insurance plan allows $35.00 for an office visit based on the negotiated contract rate. If your copay is $20.00, your insurance plan then pays $15.00 towards the visit via the claims payment, resulting in a combined total amount between the two equaling $35.00. (A-Patient Copay + B-Claims Payment = C- Claims Contract Rate)

Deductible– This is a set amount agreed upon when selecting your insurance plan, you are responsible for paying the first dollar amount in medical care. For instance, if your deductible is $1500.00 per year, each time you or your family member receives medical care, you pay the doctor for services rendered instead of your insurance plan paying the doctor until you have reached $1500.00 of medical care. Once your deductible is met, your copay or co-ins amount kicks in for the remainder of the year. Deductibles start over on an annual basis. Find out when your calendar year begins!

Co-Insurance– A percentage you pay towards services provided by your doctor that is part of the whole payment allowed by your insurance plan, typically after your deductible has been met. The percentage is based on the amount your insurance plan allows for certain services. For instance, your insurance plan allows $100.00 for a procedure of visit and you have a 10% co-insurance. Your co-ins amount due would be $10.00. $50.00 would be $5.00 and so on.

EOB– Explanation of Benefits (this is a statement or breakdown that your insurance carrier will send you after they have processed a claim. An EOB will include the date of service, procedure of visit type, billed amount, amount allowed by your insurance plan and what cost you are responsible for. It will state what is applied to deductible, copay or coinsurance)