INSURANCE VERIFICATION

INSURANCE TERMINOLOGIES

HEALTH INSURANCE – product that covers the subscriber’s medical expenses. It provides coverage if
they get sick or injures. Health insurance also covers preventive care

HEALTH INSURANCE PREMIUM – The amount that the subscriber pays for his/ her health insurance.

-payment could be monthly (most common), quarterly, semi-annually or

annually

HEALTH INSURANCE FORMULARY – It is the list of prescription drugs that is covered under the patient’s
plan

OUT OF POCKET MAXIMUM/LIMIT –it is the most you’ll have to pay for covered health care services in a
year if you have health insurance

- Deductibles, copayments and coinsurance count toward your out of pockey maximum (monthly
premiums don’t)
- After you meet the maximum out of pocket amount, your insurance will start to cover 100% of
your medical bills; it is when you stop paying your copay if you have one
- The out-of-pocket maximum resets annually
- For the 2021 plan year: the out-of-pocket limit CANNOT be more than $8,550 for an individual
and $17,100 for a family.

COPAY – (copayment) it is a fixed amount that is paid for certain health care services as determined by
his or her health plan

DEDUCTIBLE – is the amount that you must pay before your health insurance begins paying for covered
medical expenses (before coinsurance kicks in)

COINSURANCE – is the percentage (of medical costs) that you share with your insurance after meeting
your deductible.

ANNUAL PHYSICAL – aka preventive care is 100% covered by most health insurance plans

PPO (PREFERRED PROVIDER ORGANIZATION) –the type of insurance where subscribers have the option
of choosing between an in-network doctor (who can you see at a lower cost) or an out-of-network
physician (at a higher cost); plans have both in-network & out-of-network benefits.

HMO (HEALTH MAINTENANCE ORGANIZATION) –the type of insurance that will ONLY cover in-network
providers (do not cover out-of- network doctors and services)

PRIMARY INSURANCE – it is always billed first when you receive health care; it is the plan that pays the
claim as if it were the only source of health coverage.
SECONDARY INSURANCE – it is the plan that covers some or all of the cost not paid by the primary
insurance.

COORDINATION OF BENEFITS – it is the process of determining coverage between the primary and
secondary insurance.

MEDICARE – medicare is federally funded insurance for people aging 65 y/o or older and for people with
chronic conditions or disabilities

- Designed to cover your essential medical needs , such as hospital stays and doctor visits. The
program is composed of 4 parts – A,B,C,D.
- MEDICARE PART A – Hospital insurance
- MEDICARE PART B – Medical insurance; covers certain doctor’s services, outpatient care,
medical supplies and preventive services
- MEDICARE PART D – prescription drug coverage
- MEDICARE PART C – Medicare Advantage; combine part A and part B coverage and often include
drug coverage (part D) as well – all in one plan.

MEDICAID – an assistance program. It serves low-income people of every age. Patients usually pay no
part of costs for covered medical expenses. A small co-payment is sometimes required. Medicaid is a
federal-state program. It varies from state to state.

- *if px=2 insurance, Medicaid will be secondary insurance.

INSURANCE VERIFICATION

- Process of checking patient’s insurance coverage and benefits prior to date of service

Steps

1. Maintain accurate recoreds

a. Make sure that px info is up to date
i. Name
ii. Date of birth
iii. Name of person who is the primary insured
iv. Social security number (optional)
v. Insurance ID number and Group number
b. Request photo ID and the original health insurance card from patient
i. Make copies to place in the paper file or scan for electronic filing.
c. Verify insurance info through phone or computer-based web portals to confirm
coverage
i. A toll free number is generally noted on the back of the insurance card, along
with other relevant contact info for the health insurance company. We call the
provider’s hotline
d. Find out whether or not the patient will be covered on the date of service
 i. If your patient has an appointment in the future, it is important to clarify
whether or not his insurance will be valid on the date.
e. Verify whether the provider is in or out of network
i. This refers to whether you, as a healthcare provider, are an in-network
healthcare provider or out of network healthcare provider in the patient’s plan.
f. Clarify the benefits under the patient’s plan
Ask for the ff.
i. Copay
ii. Deductible
iii. Coinsurance
iv. Out of pocket maximum
v. Is the patient eligible for annual physical

*take note of the call reference number; other web postals generate a reference number for
your injury.
Provider- Dr. Mark Christian Carnett NPI:1234567890 Agent : First name, First letter of Last
name