Insurance

billing, coverage, and claims

17 terms

• Adverse Determination Basic -- A formal decision from your plan saying it will not pay for a service or will pay less than requested.
• Allowed Amount Basic -- The discounted price your insurance uses to figure what it will pay and what you may owe.
• Annual Maximum Basic -- The most your dental plan will pay for covered care in a year.
• Appeal Basic -- When you ask your insurance company to take another look and change a decision not to pay for care.
• Balance Billing Intermediate -- When a provider bills you for the leftover difference after your plan has paid what it will pay.
• Coordination of Benefits (COB) Intermediate -- How two or more plans decide who pays first and how much each will pay so the total does not go over the bill.
• Copayment Basic -- The set amount or percentage you pay when you get a dental service.
• Deductible Basic -- The amount you pay out of pocket each year before your dental plan starts paying.
• External Review Intermediate -- A review by specialists outside your insurance company to decide if it should pay for a service it denied.
• Fee schedule Intermediate -- The list of set amounts your insurance plan will pay for each type of dental work.
• Grievance Basic -- A written complaint you send when you are unhappy with your plan or the service you received, not just about a single bill.
• Internal Appeal Intermediate -- The first step where your insurance company reviews its own decision after you send an appeal.
• Maximum allowable charge Intermediate -- The most your insurance plan will pay for a specific procedure — amounts above that are your responsibility.
• Non-covered service Basic -- A dental service your insurance plan does not pay for, which means you pay the full cost.
• Out-of-pocket maximum Intermediate -- The most you would ever have to pay in a year before your insurance covers everything — if your plan has this feature.
• Timely Filing Intermediate -- A rule that says claims must be sent in on time; if they are late, the insurance can refuse to pay.
• Usual, Customary, and Reasonable (UCR) Intermediate -- A typical or average fee your plan thinks is reasonable for a service in your area, used to decide how much it will pay.