Beginner
Provider
A healthcare professional or organization that furnishes or supports healthcare services. A common beginner confusion: The word provider does not always mean the same person or organization in every field.
Payer
An organization that processes benefit and claim responsibility under a health plan or program. A common beginner confusion: Payer, plan, network, and employer are related concepts but not interchangeable.
Eligibility
A status indicating whether coverage appears active for a person and relevant date under a plan response. A common beginner confusion: Active eligibility is not a guarantee of coverage or payment.
Benefits
Plan information describing how certain covered services may be processed under stated conditions. A common beginner confusion: Benefits are not the same as eligibility and are not a payment guarantee.
Deductible
An amount a member may need to pay for applicable covered services before or alongside plan payment, subject to plan rules. A common beginner confusion: A deductible is not automatically the amount due at every visit.
Copay
A stated fixed cost-sharing amount that may apply to a service under plan rules. A common beginner confusion: Copay, coinsurance, and full patient responsibility are not the same thing.
Coinsurance
A percentage-based cost-sharing amount that may apply to an allowed amount under plan rules. A common beginner confusion: Coinsurance is not a fixed copay and should not be calculated without approved context.
Out-of-pocket max
A plan-defined limit on certain member cost sharing during a benefit period, subject to plan rules and exclusions. A common beginner confusion: The out-of-pocket maximum is not automatically the most a person can ever be billed.