Don’t understand some of those tricky words and terms your health insurance company uses? Here are some quick definitions and explanations to help you better understand your health insurance and get the most out of your plan.
Access: The availability and quality of medical care determined by location, transportation, and types of medical care facilities available.
- Example: John Smith lives in Las Vegas and has access to a car, the bus system, taxis/Uber, and other forms of transportation. He also has access to a number of medical facilities in the area that serve different types of medical conditions.
Allowed Amount: The amount your insurance company has determined is an appropriate payment for the service(s) rendered or such other amount as the Plan Provider your insurance plan have agreed will be accepted as payment for the service(s) rendered.
- For example: You go to your provider (doctor) for a checkup and the total charge for that visit comes to $100. If your provider is a member of your health insurance company’s network, he/she may require $70 as full payment for the visit, which is the Allowed Amount. Your health insurance company will then pay all or a part of the remaining $70 minus any co-payment or deductible you might owe.
Appeal: A special kind of complaint you make if youdisagree with a decision to deny a request for health care services, prescription drugs, payment for services, and/or prescription drugs you already received.
- You may also make a complaint if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if your health insurance plan doesn’t pay for a drug, item, or service you think you should be able to receive.
Definitions found at eHealth. For more health insurance definitions please visit eHealth Health Insurance Glossary.
Published February 7, 2018
