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Frequently Asked Questions
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    *  WHAT IS A PPO?       Preferred Provider Organization - A network of providers such as physicians and hospitals, which have contracted with a carrier to accept an agreed level of payment, provided to persons insured by that carrier.     * WHAT IS A POS?       Point Of Service - A network of providers designed to be accessed through a Primary Care Physician (PCP). The subscriber is generally required to go to or through their PCP to receive maximum reimbursement levels allowed.     * WHAT IS AN HMO?       Health Maintenance Organization - An organization of physicians that provide comprehensive health care, in which you select a Primary Care Physician to manage all of your health care needs. If you do not go to or through your PCP generally you may receive a reduction in benefit levels on reimbursement or coverages.     * WHAT IS AN EOB?       Explanation Of Benefits - A form from insurance carriers that explains how your claim has been paid to the provider.     * WHAT IS A DEDUCTIBLE?       The portion of a covered claim that the subscriber (or insured) is responsible to pay.     * WHAT IS FAMILY DEDUCTIBLE?       The combined deductible that a family is responsible to pay.     * WHAT DOES DATE OF SERVICE MEAN?       This would be the date your services were provided by a physician or facility.     * WHAT IS MAXIMUM OUT OF POCKET?       This is a combination of the deductible and insured¹s share of co-insurance based on the allowed amount per calendar year. Co-pay usually does not apply to the maximum out of pocket limit.     * WHAT IS UCR?       Usual, Customary, and Reasonable - That amount determined to be accepted as usual, customary and reasonable. This is the amount that is computed for reimbursement after deductible and co-insurance.     * WHAT IS CO-INSURANCE?       This is the amount of payment shared by the insured and the insurance carrier, which is generally a percentage, i.e. 80/20, 90/10, 100%, etc.     * WHAT IS CO-PAY?       A preset amount paid by the insured for specific pre-determined service such as office visits, well childcare, emergency room, etc.     * WHAT DOES BILLED AMOUNT MEAN?       The charges billed by the provider for services rendered.     * WHAT DOES ALLOWED AMOUNT MEAN?       The amount determined to be accepted by the insurance carrier as the Usual, Customary and Reasonable (UCR) based on the carriers contract.     * WHAT IS COB?       Coordination Of Benefits Provision - A group health insurance policy provision designed to prevent duplication of benefits when an individual or family is covered by more than one policy. Also, when more than one member of the family has health insurance, a decision as to coordinate payment between the two carriers the Employee¹s insurance is always primary with the spouse secondary. For the children, the Birthday Rule applies.     * WHAT IS A BIRTHDAY RULE?       A rule that uses the birthday of the subscriber to determine which carrier is primary when a coordination of benefits is required for dependents. It states that the subscriber whose birthday falls first in the year (month and day) regardless of age is primary.     * WHAT IS A CERTIFICATE?       The document explaining the coverages in general for a policy that has been written for an insured. Also known as the benefit booklet.
FAQ’s