For your convenience, Somerset Medical Center has included a glossary of health insurance terms that have been used here and/or may be used in discussions you may have with your plan's customer service representatives.
Written approval from your insurance carrier to receive medical care at Somerset Medical Center. Please note that a new authorization is needed for each type of service, such as chemotherapy, radiation therapy, MRIs, CT scans, outpatient surgery and each admission.
The amount (usually a percentage) of the health care costs for which you have to pay. You pay co-insurance even if your deductible has been met. For example, you may pay 20 percent of the cost of medical services after meeting the deductible.
A flat fee that you pay for health care services from an in-network provider for certain services such as an office visit or physical therapy. For example, you may be responsible for a $10 "co-payment" for each office visit.
The amount you must pay for health care expenses before your insurance company begins to pay for covered
Somerset Medical Center employee who is available to answer questions you may have or to explain billing procedures.
Health Maintenance Organization (HMO)
A managed care plan that requires its members to use the services of their network of physicians, hospitals, or other health care providers. If you're a member of an HMO, you are required to choose a primary care physician who must provide you with a referral to see a specialist.
Indemnity Health Plans
Also called a fee-for-service plan. An insurance plan that allows you to see medical providers of your choice. You are responsible for paying a percentage of total charges no matter which medical provider you see.
Physicians, hospitals, or other health care providers who have a managed care contract with your insurance plan. The fees of these providers are covered by the plan. You may still be responsible for deductibles, co-insurance or co-payment.
An insurance plan that contracts with a network of health care providers. Your financial responsibility is significantly less when provided in-network. EPOs, HMOs, POS and PPOs are managed care plans.
A program that provides medical benefits to eligible people who have a low income level and people with disabilities needing health care. The federal and state governments share the program costs.
A federal health insurance program that covers the cost of hospitalization, medical care and some related services for people 65 years or older and for people with disabilities.
A group of physicians, specialists, hospitals, outpatient centers, pharmacies and other providers who are contracted with an insurance company to provide health care services to their subscribers.
Non-Covered Procedure or Service
A medical procedure or service that an insurance plan considers medically unnecessary (or experimental) and therefore does not cover.
The amount you are responsible to pay for medical services, which are not reimbursed by your insurance plan.
Physicians, hospitals or other health care providers who do not have a managed care contract with an individual's insurance company. When you receive care "out-of-network," you will be financially responsible for that care.
Point of Service (POS)
An HMO plan that also includes an indemnity plan option. You can decide whether to go to a network provider for lower out-of-pocket costs, or go to an out-of-network provider with higher out-of-pocket costs.
Obtaining authorization from your insurance plan for any hospital admission and those outpatient procedures specified under your policy.
Preferred Provider Organization (PPO)
A health plan that contracts with a group of providers to offer medical services at discounted rates. Typically you can see any doctor in the PPO network without requiring special approval, and you usually do not need to choose a primary care physician. PPOs allow you to seek care outside of the PPO network; however, the benefits are usually reduced, and the insured party has a greater out-of-pocket expense.
Primary Care Physician (PCP)
A general or family practitioner who is your personal physician and first contact within a managed care system. The PCP will usually direct the course of your treatment and refer you to other doctors and/or specialists in the network if specialized care is needed.
Any medical professional (physician, nurse practitioner, etc.) or institution (hospital, clinic, etc.) that provides medical care.
The approval form you receive from your primary care physician for you to see a specialist or get certain services. In many managed care plans, you need to get a referral form or slip before you get care from anyone except your primary care doctor. If you do not first get a referral, the plan may not pay for your care.
Usual, Customary & Reasonable (UCR), or Reasonable & Customary
Every insurance carrier has a payment rate for each test, procedure and medical service. The rates are what the insurer has decided are appropriate for these services in New Jersey. Health plans have different methods to determine what is usual and customary. Somerset Medical Center's charges may be different from an insurer's rates due to the complexity of treatment, as well as the high level of care provided to our patients. If you have out-of-network benefits, you are responsible for paying the difference between Somerset Medical Center's charges and the carrier's usual and customary allowances in addition to their co-insurance and deductible costs.