Part of what makes health insurance complicated is all the specialized language. Here are some of the keywords and phrases to know when reviewing your plan:
The maximum cost that your insurance company has determined is appropriate for a specific service. Out-of-network reimbursement is based on the allowed amount for the service your child receives, rather than the actual amount charged by your provider.
The amount you have to pay each time your child receives medical care. The copayment is a part of the total cost of care. For example, if your child’s doctor charges you $ 100 and your copay is $ 25, you pay $ 25 and your insurance company $ 75. For out-of-network providers, this cost is sometimes called coinsurance. Coinsurance is usually a percentage of the total cost of the service rather than a dollar amount.
CPT stands for “current procedural terminology”. This is a series of numbers linked to a specific treatment, such as an individual psychotherapy session or a medication management visit with a psychiatrist. Insurance companies use CPT codes to guide reimbursement for treatment.
The amount you have to pay for your child’s health care each year before your insurance company begins to pay for the care.
Within the network
Network providers have a contract with your insurance company. The insurance company pays them directly for providing care.
NPI stands for “national provider identifier”. It is a unique number that is used to identify a specific healthcare provider.
Off the grid
Out-of-network providers do not have a contract with your insurance company. If a provider says they don’t accept your insurance, they are out of network. Your insurance plan may reimburse you for part of the cost of an out-of-network provider visit, but it does not directly pay for the care.
Pre-approval or pre-approval is an agreement with your insurance company for you to pay for a specific service. Some companies require that you get prior approval before you receive care for the company to pay for it. This is sometimes called prior authorization.
The price you pay each month for your insurance coverage.
The person who provides health or mental health treatment. A provider of mental health services for children can be a psychiatrist, one psychologist, social worker, or other professional.
A note from a doctor stating that it is medically necessary to see another doctor. For example, your child’s pediatrician may refer him to a psychiatrist if he needs more specialized care. Some insurance companies require a referral to pay for mental health care.
A document that includes the details of all the care your child received during a given period. If you use out-of-network benefits, your provider can give you a detailed report (also known as a superbill or superbill) to send to the insurance company with your reimbursement request