Terms You Should Know to Understand USA Insurance

Allowed Amount

　In medical services covered by insurance, the amount covered by insurance benefit calculation. Sometimes called Eligible Expense, Payment Allowance, Negotiated Rate. If your healthcare organization charges you for more than the Allowed Amount, the difference may have to be paid by the insured.

Balance Billing

　It is called Balance Billing that the medical institution charges the difference between the amount of money for the medical service and the Allowed Amount that the insurance company targets for the benefit payment. If you are a homecare agency or provider of home healthcare services you should definately buy a good software with complete billing syste. myEZcare is a such healthcare software provider which helps you in complete claims processing with its advanced billing feature.

Co-Insurance (Insurance ratio)

In medical services covered by insurance, the percentage of medical expenses paid by the insured person for the Allowed Amount subject to insurance benefit reimbursement. When Deductible is set, both Co-Insurance and Deductible are self-paying. 

Co-Payment

　When receiving medical services covered by insurance, Co refers to the fixed amount paid to medical institutions (eg, $ 15 per hospital visit), and Co to the percentage of medical expenses paid by insurance subscribers. -It is different from Insurance. The amount may vary depending on the type of medical service, such as the clinic or hospital.

Deductible

　The amount that the insurer pays before the insurance company starts claim payments. For example, if Deductible is $ 2,000, the medical services covered by Deductible cannot receive insurance payments unless they pay all for up to $ 2,000. Not all medical services, such as some preventive medical services, are eligible for Deductible.

Of–Out Pocket-Maximum 

The maximum amount of medical expenses paid to be covered by insurance. In principle, the insurance company pays 100% of “Allowed Amount” for the payment of medical expenses exceeding the upper limit. It is required that payments for medical services must be included in the calculation of Out-of-Pocket Maximum. In addition, payments for medical services other than Balance Billing and Essential Health Benefits when using medical institutions outside of premiums and networks need not be included in the calculation of Out-of-Pocket Maximum.

UCR (Usual, Customary and Reasonable)

UCR is generally used to set Allowed Amount when using a medical institution outside the network. The standard amount of medical expenses set for each area based on the amount that the same or similar medical services are generally charged within the same area.