Healthcare Call Center Evaluation & Reference Guide

The maximum dollar amount a health plan will reimburse for a specific covered service.

When an out-of-network provider bills the patient for the difference between their billed charge and the insurance allowed amount.

A medical claim submitted with complete, error-free data allowing prompt processing and payment without requiring manual review.

An intermediary entity that reviews, formats, and transmits electronic claims between healthcare providers and insurance payers.

A percentage of the allowed medical cost shared between the health plan and the member (e.g., 20% patient share).

The process determining primary and secondary payment responsibility when a member has coverage under two separate plans.

A fixed flat fee paid by the member at the time of receiving a medical service or prescription fill.

The amount a member must pay out-of-pocket for covered medical care before the health insurance plan begins contributing.

A statement sent to the patient explaining how a claim was processed, detailing what the plan paid and what the member owes.

A comprehensive list of prescription drugs covered by a health plan, typically organized by cost tiers.

A plan type requiring members to use a strict network of doctors and obtain PCP referrals for specialist visits.

The absolute maximum amount a member pays for covered services in a plan year before insurance covers 100% of costs.

A plan offering greater flexibility to see out-of-network providers without referrals, usually at higher out-of-pocket rates.

Advance approval obtained from a health plan confirming coverage for a specific medical procedure, treatment, or drug.

An itemized billing form (CMS-1500) generated from provider superbills used to submit outpatient medical claims.