Hint
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Answer
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The maximum amount on which payment is based for covered health care services. If your provider charges more, you may have to pay the difference.
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A
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Allowed amount
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A request for your health insurer or plan to review a decision or a grievance again.
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A
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Appeal
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Billing from the provider for the difference between their charge and the amount allowed by your health plan.
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B
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Balance billing
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Your share of the costs of a covered health care service, calculated as a percent of the allowed amount for the service.
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C
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Co-insurance
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A fixed amount you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
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C
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Co-payment
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The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay.
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D
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Deductible
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Equipment and supplies (e.g., crutches, blood glucose testing strips, oxygen) ordered by a health care provider for a patient’s everyday or extended use.
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D
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Durable medical equipment
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Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
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E
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Emergency services
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Health care services that your health insurance or plan does not pay for or cover.
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E
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Excluded services
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A formal complaint you communicate to your health insurer or plan.
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G
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Grievance
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Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
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H
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Hospice services
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Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
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M
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Medically necessary
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The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services.
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N
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Network
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The maximum you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn't cover.
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O
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Out-of-pocket limit
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A provider who has contracted with your health insurer or plan, but whose discount may not be as deep as other preferred providers.
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P
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Participating provider
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A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. This decision does not guarantee payment.
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P
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Preauthorization
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A provider who has a contract with your health insurer or plan to provide services to you at a discount.
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P
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Preferred provider
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The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.
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P
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Premium
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A physician, nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.
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P
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Primary care provider
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A physician, health care professional or health care facility licensed, certified or accredited as required by state law.
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P
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Provider
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Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled.
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R
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Rehabilitation services
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Services from licensed nurses in your own home or in a nursing home.
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S
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Skilled nursing care
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A physician who focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions; or a non-physician provider who has more training in a specific area of health care.
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S
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Specialist
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Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency care.
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U
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Urgent care
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The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. Sometimes used to determine the allowed amount.
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U
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Usual, customary and reasonable
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