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Understanding insurance terms

A guide to key insurance terms

It’s important to understand your health insurance benefits and how your claims are processed. Your insurance provider will send you an Explanation of Benefits (EOB) document to explain what was paid or denied on your claim.

Understanding key terms can help you make sense of these complex documents. While each insurance provider uses a unique format for EOBs, they all typically include the following common language and information.

Term Description
Account number or invoice number Each bill is given a number by the service provider, such as the hospital, doctor, or lab. Quest uses the term "Invoice#."
Amount paid The part of the bill that has been paid by the insurance company.
Allowed charges The part of the bill that the insurance company approved to be paid.
Capitation accounts These clients (such as HMOs, IPAs, physicians, etc) pay a fixed rate based on the number of members and/or tests per month. Capitated clients usually provide services for HMOs. (See also: IPA)
Claim number Your insurance company gives each claim a number. This number is often on the insurer’s reply to Quest when handling your claim.
Coinsurance The part of the bill that must be paid by the patient. It is usually a certain percentage.
Contract charges The part of the bill that you and your insurance do NOT need to pay to Quest. This amount is based on a contract between the insurance company and Quest.
Coordination of benefits The part of the bill that must be paid by another insurer. This happens if you have coverage from more than one insurance provider.
Copay The part of the bill that must be paid by the patient. It is usually a fixed dollar amount. The copay is typically paid at the same time you have the service.
Date of service The date when the lab testing was performed.
Deductible The amount you pay for covered services in a year before your insurance starts to pay.
Excess over UCR The part of the bill that exceeds charges allowed by your insurer. This amount is based on contracts between the insurer and Quest. UCR stands for usual, customary, and reasonable. (See also: UCR)
Explanation of payment The section of an EOB that explains how payments were made and any payment codes used.
In-network These healthcare providers partner with your insurance plan for discounted rates. Find out if Quest is in network with your plan. Use our Insurance Providers search tool.
IPA Stands for Independent Practice Association. It is a group of independent doctors. (See also: Capitation Accounts)
Non-covered A service NOT included in your insurance coverage. It won’t be paid by your insurer. You may have to pay this amount.
Patient information Your personal details. This includes patient name and ID. It also includes responsible party, subscriber and more.
Patient responsibility The patient must pay this part of the bill to the provider (such as Quest.) This includes "not covered" amounts, deductibles and any part of the balance. Note: This does not include copays. But copays are also the patient’s responsibility.
Preferred lab network (PLN) Health insurance companies assign preferred status to the laboratory providers that meet or exceed important standards. Some of the criteria include high quality of care, low average costs, easy experience, short wait times, and fast results. When they choose a lab in their preferred lab network, health plan members typically pay even lower costs for testing than when using another in-network provider.
Provider information The name and address of the service provider or payee. It may also include the account and provider numbers.
Service code This code indicates the service provided.
Submitted charges The amount Quest billed you or your insurance company.
Units The number of items in the health or testing service you received.
UCR This stands for usual, customary, and reasonable. The fee for services based on what local providers charge. (See: Excess Over UCR)

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