A health care provider is a medical professional or facility licensed to provide care and treatment services.

The amount an individual, or family, must pay out-of-pocket before your plan pays their contracted amount.

Is the fee individuals or families must pay each time they use their insurance at a doctor’s office or medical facility.

The percentage of medical costs an individual or family pays once the deductible has been met.

You are also responsible for any fees not covered by the health plan (patient responsibility).

This is the amount patients must pay the provider.

Most plans have an allowed amount based on the insurance companies internal fee schedule.

If the provider is contracted with the insurance carrier (In-Network). A patient’s financial responsibility can be a combination of their deductible and shared costs.

If the provider is Out-of-Network, then the patient responsibility is any amount unpaid by the insurance plan.

The most an individual or family is expected to pay for covered medical expenses in a single calendar year; is deductible, copay, and coinsurance.

Once the maximum is met, the insurance plan will pay your covered medical and prescription costs for the remainder of the year.

Claims are a request for payment either you or your healthcare provider sends to an insurance company for services.

The EOB is a statement from the insurance company letting a policyholder know what claims have been processed, what covered services were paid, and what amounts the patient is responsible for under their plan.

Patients who seek care from Out-of-Network providers are financially responsible for differences between the charge submitted for services provided and the allowed amount on an insurance plan.

Surprise Billing is when the patient is billed for unpaid services, without knowing their insurance company didn’t pay the expected amounts.