Glossary of Billing Terms
Allowable
The dollar limit your insurance company will pay for any given service. This amount is almost always less than the reasonable and customary fees charged by most medical providers and may vary between insurance companies. Insurance companies establish their “allowable” amounts as a way to limit their financial liability and control their costs. This amount in no way reflects the value of the service or the appropriate amounts medical providers charge. The difference between the “allowable” amount and the actual provider fees charged is the responsibility of the insured patient. Keep in mind that it is the insurance company who has shifted this financial burden to the patient, not the medical provider. Interestingly, not all insurance companies will disclose their so-called “allowable” amounts to medical providers.
Appeal
Balance Billing
Co-Payment & Co-Insurance
Deductible
Durable Medical Equipment (DME)
Group Policy
An insurance plan purchased and maintained by an employer or other group on behalf of its employees or members.
Individual Policy
An insurance policy purchased by an individual for personal use, rather than an employer.
Managed Care
These plans are common in the Lower 48 states. Plans are designed for cost containment. Structuring of these plans may vary, and referrals to a specialist are commonly required for payment. Please check your benefit plan for specific provisions. You must have a referral from your Primary Care Provider (PCP) if you are on a managed care or HMO plan. Without this your Insurance will not cover your costs.
Out of Pocket (OOP)
The amount that must be spent by the patient (deductible + co-payments) before the insurance company begins to process claims at 100% of the company’s allowed amount.
Pre-Certification
The process completed to inform insurance of upcoming procedure, such as surgery. OPA will contact your insurance carrier prior to surgery. We are able to communicate necessary information to your carrier, and check benefits. Please understand this is not a guarantee of payment. Patients are always encouraged to contact insurance personally to check benefits, and other policy provisions that may affect their payment requirements or claim processing. Some plans require pre-certification before other procedure types are performed. Please check your benefit booklet or contact your H.R. department for specific information.
Surgical Assistant
Some surgical procedures require the assistance of a second provider. The need for the surgical assist will be made by your surgeon, and is based solely on medical necessity.
Questions?
The OPA team includes Alaska’s leading specialists and offers some of the latest, most advanced treatment procedures available today.
OPA treats a wide variety of conditions and offers comprehensive treatment options — including many non-surgical solutions, minimally invasive arthroscopies (repairs), and total joint replacement.