Patient Resources - Business Office Glossary of Terms
Maximum Lifetime Benefits – The total amount of insurance
benefits available to any one participant under an insurance plan
for a lifetime; or the total amount of lifetime benefits available
for a specific benefit, such as Infertility.
Exclusion – A procedure or service that is not covered by
your specific insurance plan.
Eligible Expense – An expense for a service that is covered
under your plan.
Pre Determination of Benefits – A request made to your
insurance carrier that asks them to provide specific coverage
details regarding a specific planned procedure.
Preexisting Condition – A condition for which medical advice,
diagnosis, care, or treatment was recommended or received during a
specific time period prior to the date that your current insurance
policy went into effect.
Network Provider – A Hospital, Physician or other provider
that has entered into a contractual agreement to provide services to
patients covered by a specific managed care plan.
Non Network Provider – A Hospital, Physician or other
provider that has not entered into an agreement to participate as a
managed care provider.
Medically Necessity – Services considered as essential for
the diagnosis or the direct care and treatment of a medical
condition. Such services are consistent with generally accepted
standards of medical practice and are not performed primarily for
the convenience of the patient or physician.
Maternity care – Care and services provided for the treatment
of pregnancy. Complications are not included.
Co pay – The set fee that a patient pays each time they have
a doctor's visit. Depending on the nature of the visit, there may
be additional charges.
Co insurance – This refers to the portion (or percentage)
of the overall medical cost of an office visit or treatment that a
patient is responsible for -- after any deductible is take care of.
For example, if you have an '80/20' plan, the insurance company will
pay 80% of the cost and the patient will pay 20% of the cost.
Allowed or Contracted Amount – The amount, determined
by a contract between a healthcare provider and an insurance carrier
that the carrier will pay the provider for a specific service.
Deductible – The fixed dollar amount you must pay out of your
own funds each calendar year before your health insurance begins to
make payments for covered medical services.
Texas Fertility Center
- 6500 Mopac, Building 1 - Suite 1200
- Austin, TX 78731
