Health Coverage and Medical Terms

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. 

Medical billing basic terms, definitions - capitation fee, covered services, dependent, emergency Medical condition

“Capitation Fee” means the monthly payment made by CarePlus to the Provider for each Enrollee assigned to Provider. The amount of the Capitation Fee is set forth in the PCP Agreement.

“Clean Claim” is a claim that has no defect or impropriety, including lack of required

substantiating documentation for non-contracted providers and suppliers, or particular circumstances requiring special treatment that prevents timely payment from being made on the claim. A claim is “clean” even if CarePlus refers it to a medical specialist for examination. If additional documentation in the medical record involves a source outside CarePlus, the claim will not be considered “clean”.

“Copayment” means the amount required to be paid by Member to Provider as additional payments

for Covered Services as are Medically Necessary and shall include fixed payments to be paid as well as percentage amounts based on the cost of a service (i.e. “co-insurance”). Copayments will vary in amount for Members, depending on benefit structure

“Covered Services” means those medical and hospital services that are expressly covered under any Subscriber Certificate and are medically necessary as determined by CarePlus’ Medical Director