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Helpful Definitions

Beneficiary: A person who receives benefits of any insurance plan or policy.

Claim: A request for payment for services submitted by the provider.

Coinsurance: A specified percentage of covered expenses which the insurance carrier requires the beneficiary to pay toward eligible medical bills.

Co-pay or Co-payment: A specific set dollar amount contracted between the insurance company and the beneficiary to be paid prior to any services rendered.

Covered Services: Services for which an insurance policy will pay.

Deductible: A specified dollar amount of medical expenses which the beneficiary must pay before an insurance policy will pay.

Guarantor: The guarantor is the person legally responsible for charges incurred.

Explanation of Benefits (EOB): A statement from an insurance company showing the processing of a claim.

Medically Necessary: Treatments or services that insurance policies will pay for as defined in the contract.

Non-Covered Services: Services for which an insurance policy will not provide payment. These services are to be paid by the patient at the time of service.

Pre-Certification/Authorization: A service-specific requirement that your insurance company’s approval be obtained before a medical service is provided.

Provider: A person or organization that provides medical services.

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