Navigating insurance can be difficult - there are many new terms for students that may not be familiar. Below are a list of common health insurance terms that are helpful to know. Each section is linked to a short video that will help and provide an explanation.
Videos
HMO
PPO
In-Network vs. Out of Network
A provider is a person or facility that provides healthcare. In-network doctors and facilities have agreed not to charge you more than the agreed-upon cost.
Providers that are out-of-network are those that do not participate in that health plan's network. The provider is not contracted with the health insurance plan to accept negotiated rates. This means that patients will typically pay more or the full amount for the service they receive.
The best way to find an in-network provider is log into your health insurance account and go to the “Find Care” section of your account.
Types of plans
HMO requires you to use doctors in the HMO network. When you sign up for a plan, you’ll choose a primary care physician (PCP). This is the person you’ll see for regular checkups. Your PCP will need to give you a referral before you can see a specialist, like a dermatologist. Because all your health services go through your PCP, it’s important to find one you trust.
POS plans may require you to get a referral from your PCP to see a specialist. This plan does cover out-of-network doctors.
EPO covers only in-network care. But the networks are generally larger. They may or may not require referrals from a primary care physician.
PPO has higher premiums than an HMO or POS. But this plan lets you see specialists and out-of-network doctors without a referral. However, out of pocket costs will be higher if you use an out of network provider.
What is a claim?
A claim is a formal request to the insurance company for payment of medical services provided to a patient. The healthcare provider will usually file the claim on your behalf. However there may be cases where you will need to file the claim.
How to File a Claim
In order to file a claim, you will need to get an itemized receipt. This itemized receipt should have diagnosis codes and billings codes.
Explanation Benefits
An Explanation of Benefits (EOB) is not a bill. This is a document we send you to let you know a claim has been processed. It’s letting you know which healthcare provider has filed a claim on your behalf, what it was for, whether it was approved and for how much. You should always review your EOB to make sure it's correct. After you receive the final bill from your doctor, compare your final bill with your EOB. The information on the EOB should match the amount you owe your doctor as listed on the bill.