Explanation of Terms

Billed Charges: The physician’s fees that are billed to your insurance company. Individual fees submitted by CornerStone Ear, Nose & Throat, PA, are the same regardless of type of insurance.

Claim: A form submitted to your insurance company for payment that shows office visits, procedures performed and associated diagnoses.

Contractual or Allowed Amount: The physician has a contract with each insurance company agreeing to accept a set amount for billed charges submitted to your insurance company. The difference between the physician’s fee and the insurance contractual or allowed amount is adjusted off the physician’s fee.

Copay: The flat fee portion of the patient’s financial responsibility for healthcare services according to your insurance plan. Copays for specialist office visits may be higher (for instance, $35) than those for primary physician office visits (for instance, $25). Copays vary from plan to plan.

Coinsurance: The percentage established in your insurance contract as being your financial responsibility. For instance, if your coinsurance is 80%/20%, your insurance company covers 80% of the contractual or allowed amount, you are responsible for the remaining 20% of that amount.

Deductible: The amount established in your insurance contract that is the patient’s financial responsibility required to be met before your insurance company begins to pay your claims. For example, if your plan carries a $500 deductible and 80%/20% coinsurance, you must pay the $500 before your insurance provider will begin to pay 80% on your submitted claims.

Explanation of Benefits or Payment (EOB or EOP): The form your insurance company will send you showing how your claim was processed, what portion of the submitted charges was allowed, paid, adjusted off and what portion is the patient’s responsibility.

HCFA: The Health Insurance Claim Form submitted to your insurance company for physician fees.
Lapse in Coverage: The number of days your insurance plan allows you to be with no insurance coverage before a pre-existing clause will apply. You will need to get this information from your insurance carrier.
Letter of Credible Coverage: A letter that can be provided from your previous insurance provider to your new insurance carrier proving that you (and your family members) were covered prior to beginning your new coverage.

Out of Pocket Expense: The amount of financial responsibility you must pay before your insurance plan begins to pay at 100% of the contractual or allowed amount.

Pre-existing Condition: A physical condition that existed and for which you received treatment prior to the effective date of your current insurance policy.
Pre-existing Condition Clause: A statement in an insurance policy that varies from plan to plan, but can require a waiting period of 6-18 months or more before they will consider claims for payment related to a pre-existing condition.

Qualifying Event: Cancellation or termination of a health insurance policy due to a change of insurance policy, resulting from employment changes or plan changes at your current employer.