Terminology

1. portion of covered expenses which is payable by the covered person and which is not applicable to the Calendar year deductible or OOP maximums
3. any covered person on whose behalf a claim is submitted for benefits under the plan
5. pariod of time commencing on Jan 1st at 12:01am until the following Jan 1st
8. usually the first doctor a patient sees for an illness
10. period of time commencing at 12:01 am on the effective date until the same following date a year later
11. the amount a participant has to pay before the plan pays for benefits that are subject to this
13. refers to providers that are not contracted with the network selected by a group

1. part of covered expenses that the plan or covered pays, not including copayment or deductible
2. an employee benefit plan funded through the employer; employer assumes all the risk
4. number that is assigned to individual claims that are filed
6. summary of benefits available to participants that specifies how the benefits will be considered
7. defined group of providers typically linked through contractual arrangements
9. employer purchases coverage from a licensed insurance company and the insurance company assumes all the risk
12. message added to a processed claim that can either explain the way on which a claim was processed or indicate additional information that may be required