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Billing & Insurances - Common Terms

Authorization is the approval of care, such as hospitalization or procedure by an insurer or health plan. Some insurers or health plans are now requiring pre-authorization before you're treated.

Copayment is the portion of a claim or medical expense that you must pay out of pocket. Copayment usually is a fixed amount and is usually information found on the front of the insurance card.  Copays will differ between your Primary Care Physician and your Specialist.

A deductible is the portion of your health care expenses that you must pay before your insurance begins to pay on your claim.

Coinsurance is a provision that limits an insurer's coverage to a certain percentage, commonly 80 percent. This provision is common among indemnity insurance plans and preferred provider plans. If your insurance includes coinsurance, you'll be responsible for charges beyond those covered by your insurance.  Coinsurance is often applied to ancillary tests such as radiology.

Pre-certification is also known as pre-admission certification, pre-admission review and pre-cert. It refers to the process of obtaining authorization from the health plan for routine hospital admissions (inpatient or outpatient) and procedures. Failure to obtain pre-certification required by the health plan will  result in the denial of the claim.

A written order from your primary care doctor for you to see a specialist or get certain medical services. In many health maintenance organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don't get a referral approved by your insurance company they will deny the claim for requested service.

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