Allowed Amount
Maximum amount on which payment is based for
covered health care services. This may be called “eligible
expense,” “payment allowance" or "negotiated rate." If
your provider charges more than the allowed amount, you
may have to pay the difference.
Appeal
A request for your health insurer or plan to review a
decision or a grievance again.
Balance Billing
When a provider bills you for the difference between the
provider’s charge and the allowed amount. For example,
if the provider’s charge is $100 and the allowed amount
is $70, the provider may bill you for the remaining $30.
A preferred provider may not balance bill you for covered
services.
Co-insurance
Your share of the costs
of a covered health care
service, calculated as a
percent (for example,
20%) of the allowed
amount for the service.
You pay co-insurance
plus any deductibles
you owe. For example,
if the health insurance or plan’s allowed amount for an
office visit is $100 and you’ve met your deductible, your
co-insurance payment of 20% would be $20. The health
insurance or plan pays the rest of the allowed amount.
Complications of Pregnancy
Conditions due to pregnancy, labor and delivery that
require medical care to prevent serious harm to the health
of the mother or the fetus. Morning sickness and a nonemergency
caesarean section aren’t complications of
pregnancy.
Co-payment
A fixed amount (for example, $15) you pay for a covered
health care service, usually when you receive the service.
The amount can vary by the type of covered health care
service.
