Frequently Asked Questions
Commonly Used Terms
A copayment is a fixed amount that the patient must pay the provider at the time of treatment Coinsurance is a percentage you share with the insurance company after the deductible has been met. If there are two insurance companies, the primary insurance will pay first (after the deductible has been met), and then the secondary pays the balance.
What is the difference between a “prescriber” and a “non-prescriber”?
A prescriber can write prescriptions, an MD, PA or NPP, and a non prescriber, Psychologist or LCSW, cannot write prescriptions for patients.
This is the dollar amount considered payment‐in‐full by an insurance company.
Permission from the insurance company that allows for a provider to render services and be reimbursed. This could be for a specific number of sessions or a specific date range or both.
When services are covered under your plan. It also defines the time when benefit maximums, deductibles and coinsurance limits build up. It has a start and end date. It is often one calendar year for health insurance plans Example: You may have a plan with a benefit period of January 1 through December 31 that covers 10 therapy visits. The 11th or more session will not be covered.
COB Coordination of Benefits:
Allocation of payment responsibility when a patient has 2 or more health insurance (Primary, Secondary, Tertiary).
A fixed amount that is owed by patient for each date of service provided
A percentage that is owed by patient for each date of service provided. Amount is a percentage of allowed amounts.
EPO (Exclusive Provider Organization):
The patient only has benefits available to see in-network providers. There are not out of network benefits available on these types of plans.
HMO (Health Maintenance Organization):
Offers healthcare services only with specific HMO providers. Under an HMO plan, you might have to choose a primary care doctor. This doctor will be your main healthcare provider. The doctor will refer you to other HMO specialists when needed. Services from providers outside the HMO plan are hardly ever covered except for emergencies
INN (In Network):
An in‐network provider is one contracted with the health insurance company to provide services to plan members for specific pre‐negotiated rates
A type of health insurance that covers certain services over a set amount of time (typically, a 12‐month period).
Member ID Number:
A unique set of numbers and/or letters that identifies the patient in the insurance companies operating system
Charges for services and supplies that are not covered under the health plan. Examples of non‐covered charges may include things like acupuncture, weight loss surgery or marriage counseling. Consult your plan for more information. (EXCULSIONS)
OON (Out of Network):
An out‐of‐network provider is one not contracted with the health insurance plan
OTR (Outpatient Treatment Review Form):
A form that is sometimes required when insurance requires prior authorization
OOP (OUT OF POCKET):
Out‐of‐pocket maximum/limit definition: The most a patient must pay for covered services in a plan year. After the patient spends this amount on deductibles, copayments, and coinsurance, the health plan pays 100% of the costs of covered benefits.
A specific number of sessions that are allowed before pre‐certification is required.
SCA (Single Case Agreement):
An agreement between an out-of-network provider and the insurance company that creates a contract for only one patient. This allows the provider to be paid directly from the insurance company. This would only apply if there were not out of network benefits on the plan.
POS (Point of Service):
A point of service plan is a type of managed care health insurance plan in the United States. It combines characteristics of the health maintenance organization (HMO) and the preferred provider organization (PPO). The POS is based on a managed care foundation—lower medical costs in exchange for more limited choice.
PPO (Preferred Provider Organization):
A type of insurance plan that offers more extensive coverage for the services of healthcare providers who are part of the plan’s network, but still offers some coverage for providers who are not part of the plan’s network.
What is an ERA?
An ERA, or electronic remittance advice, is an electronic explanation of payment from insurance companies. They explain the allowed, paid, and any patient responsibility amounts on the claims with respect to the charge amount. These may be sent in place of or in addition to paper remittances that you may receive. It is important to note that if you are an out-of-network provider, ERA’s may not be supplied.
Current Procedural Terminology. This is the medical code that is used to report procedures and services.
This is the diagnosis code for your patient. You should be submitting an ICD 10 diagnosis from the DSM 5 for behavioral health. Many providers have “Z” codes or various other “F” codes they would like to be included, and these should be listed as secondary dx’s to the primary dx from the DSM 5.
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