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Insurance Common Questions |
Some simple answers for common questions about basic Insurance benefits
What is the difference between an In Network and Out of Network provider?Network providers have contracted with your insurance company and have agreed to accept an agreed upon fee schedule know as Allowed Charges, for the medical services you are provided. Network providers have agreed they will not bill the insured for any amount greater than their insurance plan’s Allowed Charges for eligible medical services and supplies.
Non Network providers do not have a contract with your insurance company and are not limited to your health plan’s Allowed Charges amount. The insured is responsible for all billed charges.
What is a co-pay? Co-pay is a set amount a member pays for a specific service, such as a set dollar amount for a Doctors office visit.
What is an Allowed Charge amount? The maximum dollar amount allowed for a service or supply covered by your insurance plan.
What is a deductible?A deductible is the initial out of pocket amount that a member pays on ALLOWED CHARGES before a benefit is paid by your insurance company plan benefit.
What is Co-Insurance?
Co-insurance is also known as patient portion of payment.
Co-Insurance is the portion of eligible expenses the member is financially responsible for usually based on a fixed percentage. Deductible amount must be met before co-insurance applies to the patient.
Example (In network) When your deductible is met for the current year. You receive medical services that cost $500.00 and your insurance company allows $200.00. The member’s financial responsibility is (20% of $200.00) or $40.00. The provider adjusts off the $300.00 over the approved amount. The $40.00 fee is your co-insurance that goes towards your out of pocket maximum.
The member is also responsible for any amount above the allowed amount.
Example (out of network) When your deductible is met and you receive medical services totaling $300.00 the allowed amount is $250.00. Unless other arrangements are made the member would be responsible for the $50.00 difference between the BILLED amount and the Allowed charges. You would also be responsible for the co-insurance allowed amount of $125.00 or (50% of $250.00). Your total responsibility would be the $50 + $125 for a total of $175.00 but only the allowed amount $125.00 goes towards the out of pocket maximum.
What does out of pocket maximum mean? The out of pocket maximum is the total amount of allowed charges that a member will be responsible for, before their insurance plan pays 100 %.
Not all member expenses apply towards the out-of-pocket maximum.
 What is pre-certification?
Pre-certification is a review process the insurance company may require for certain services such as inpatient hospital admissions, outpatient surgery or in some circumstances diagnostic tests.
The patient services may not be covered by full plan benefits if pre-certification is not obtained prior to services being rendered.
Pre-certification can take up to 3 days with some companies prior to a scheduled admission.
For questions regarding scheduled procedures at the Cimarron Surgical Care Center click here
Cimarron Healthcare Center 2340 E. Main St Cushing Oklahoma 918 225-6904 www.cimarronhealthcare.com
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Surgical Care Center