Insurance Vocabulary


Ambulance Service: We use this to refer to who provided the emergency services.  It may be listed Town Of XXX,  City of XXX, XXX Fire and EMS. Each municipality does their business under a registered name. This will be on the top of the patient statement from 3 Rivers Billing.

Benefits: The money the insurance company pays the health care provider for medical services to you if you become ill or injured.

Claim: A request by you for payment by the insurance company of medical expenses that are covered under the insurance policy. The provider of a medical service will usually file a claim for you.

Co-insurance: The amount (typically a percentage) you are obligated to pay for covered medical services after you’ve satisfied any co-payment or deductible required by your health insurance plan.

Co-payment: The set or fixed-dollar amount you are required to pay each time a particular medical service is used. A co-payment for services may be $10 per visit.

Coverage: The conditions for which the insurance company will pay. Deductible: The cumulative amount that you must pay annually before benefits will be paid by the insurance company. If the insurance policy indicates a "$250 deductible," the insurance company pays as agreed after you pay the first $250.

Emergency: A severe medical condition which may include pain, loss of breathing or consciousness, heart attack, stroke, poisoning, convulsions or severe bleeding.

Exclusions: Conditions for which the insurance company will not pay; for example, cosmetic procedures. Tip--Non-transport ambulance services are sometimes excluded.

Explanation of Benefits (EOB): The statement you receive from the insurance company showing the services, amounts paid by the plan and total for which you are being billed. 

Insured: A person or organization covered by an insurance policy.

Network: A group of medical providers that are contracted with a specific insurance company for highest payment levels. Tip: Fire/EMS departments do not contract with insurance companies outside of Medicare and Medicaid.

Out-of-network care: Healthcare rendered to a patient outside of the health insurance company's network of preferred providers. In many cases, the health insurance company will not pay for these services. 

Out-of-Pocket Costs: The total you pay out of your pocket for a policy year. These costs include the deductible, co-insurance and amounts considered by the insurance company to be above the "Usual and Customary charges."

Patient Information an umbrella term which includes Insurance, Guarantor, Assignment of Benefits, Payment Authorization to name a few.

Insurance Information Request: A form used to collect personal information to acquire insurance information and collect the debt for services. Generally composed of name, birthday, phone number, insurance plan information and signatures granting use of information to bill insurance.

Usual and Customary Charges: (Also called "Reasonable and Customary Charges") The routine charge for a medical service by similar professional medical providers in the same geographical area. Tip: You may be required to pay an amount above the Usual and Customary charge when insurance does not pay the full amount. .