Allowed amount refers to the maximum amount Select Health will pay for a specific medical service or procedure. This amount is determined based on various factors, including contracts with healthcare providers, regional pricing, and the type of service provided.
Balance billing is when you receive a bill for an amount that was not included in your initial copayment or coinsurance charges. This usually happens when visiting out-of-network providers or facilities, which may charge more than the allowed amount for services.
Coinsurance is a cost-sharing arrangement where you are responsible for paying a certain percentage of your total medical costs. For example, if your health plan has an 80/20 coinsurance structure, Select Health will cover 80% of all eligible expenses. You will only pay the remaining 20%.
Coordination of benefits (COB) is a process used to determine the order in which multiple insurance policies will pay for a claim when an individual is covered by more than one policy. This situation often arises for dependents who are covered under both parents’ plans or when someone has both a primary and secondary insurance policy.
A copay is a fixed amount you pay the doctor, pharmacy, or facility toward the total cost of healthcare services. Most plans offer lower copays for Primary Care Doctors and higher copays for secondary care providers.
A health insurance deductible is the amount you pay out-of-pocket for healthcare services before your insurance plan begins to pay its share. For example, if your deductible is $1,000, you must pay the first $1,000 of your medical expenses. After you meet your deductible, your insurance will start covering a portion of your costs, typically involving copayments or coinsurance for further services. Deductibles will vary by plan.
Excess charges are any dollar amounts that exceed the allowed amount for a covered service. If you are using a participating provider, they will not ask you to pay this amount (this is called a write off). If you see a nonparticipating provider, you are responsible to pay any excess charges.
Each time we receive and process a claim, we create an EOB that explains how much we paid, how much you are responsible to pay, and more. You can receive this statement by mail, or view it online or in our mobile app
An out-of-pocket maximum (or out-of-pocket limit) is the maximum amount you could pay for healthcare services each year. The amount you pay toward your deductible, coinsurance, and copays all contribute to your out-of-pocket maximum. Once your out-of-pocket maximum is reached, Select Health will cover 100% of the cost of eligible services for the rest of the year or policy period.
Some services require prior approval from Select Health. This approval is called preauthorization. In-network providers will typically get it for you, but if you are seeing an out-of-network provider, you need to get it yourself. If a service requires preauthorization and it isn’t obtained, your benefits may be reduced or denied. For a list of services that require preauthorization, see your member materials or call Member Services.
An insurance premium is the money you pay to keep your insurance policy active. You can pay your premium online and set up auto-pay to save yourself time in the future.
A Primary Care Doctor, also known as a Primary Care Provider or PCP, can help you maintain and protect your health. The care they provide includes preventive care, like routine annual visits and immunizations, as well as treatment for minor injuries and illnesses. As your doctor learns more about your health needs, they will become a trusted health partner. Selecting a Primary Care Doctor is one of the first steps in your healthcare journey.
A subscriber is the primary account holder on your plan.