A payment arrangement gives you extra time to pay the total balance on your account. It involves scheduled payments that are automatically processed on a certain date every month, using your preferred payment method. Scripps can help you set up a payment plan or explore other types of financial assistance.
Point of service (POS)
Point of service (POS), also called a tiered plan, is a type of health insurance plan that combines certain features of HMO and PPO plans. It provides different tiers (levels) of coverage that are based on your use of in-network or out-of-network providers. Below are common tiers associated with POS plans.
Tier 1 benefits (HMO coverage) — You must choose a primary care physician (PCP) to oversee your care and help you obtain authorization for specialty services. Your only out-of-pocket costs may be the co-pays required for certain visits.
Tier 2 benefits (PPO coverage) — You may self-refer to any in-network provider without obtaining authorization from your PCP. But you may still need authorization from your insurance company. You’ll likely need to pay a deductible and a percentage of your medical costs.
Tier 3 benefits (noncontracted coverage) — The payments from your insurance company will vary, based on the specific benefits offered by your plan. If your insurance company denies your claim for noncovered services, you may be responsible for a larger share — even up to 100 percent — of the charges. Typically, if you receive care without getting the necessary authorization from your insurance company, you’re responsible for 100 percent of the charges.
The policy number is the unique number assigned to you by your insurance company. It identifies you as the policyholder or enrolled member.
The pre-certification number is a number assigned by your insurance company to indicate a medical service has been approved. However, it does not guarantee payment for that service.
A pre-existing condition is a medical illness or injury that you’ve received treatment for in the past, before enrolling in your current health insurance plan. Pre-existing conditions are often chronic (long-term). Examples are diabetes, COPD and sleep apnea.
Preferred provider organization (PPO)
A preferred provider organization (PPO) is a type of health insurance plan that allows you to see in-network doctors without a referral from your primary care physician. If you see an out-of-network provider, your PPO may cover some costs, but you will pay more than if you saw an in-network doctor. You also may need authorization from your health plan for certain services, such as physical therapy or an MRI.
Primary care physician (PCP)
Your primary care physician (PCP) is the main doctor who oversees your medical care. They can specialize in internal medicine, family medicine, pediatrics or (in some cases) OB-GYN. Most HMO, EPO and POS insurance plans require you to choose a PCP. If you don’t choose a PCP, the health plan may assign one to you. Your PCP will provide or authorize all types of care you may need, including diagnostic tests, referrals to specialists or hospitalizations. Depending on the type of insurance plan you have, your visit to a specialist may not be covered if your PCP didn’t approve it ahead of time.
Primary insurance company
The primary insurance company is the company that pays your medical claims first, if you’re covered by more than one health insurance company.
Prior authorization is another term for advance approval. It means your primary care physician (PCP), medical group or health insurance plan must approve certain services or procedures ahead of time. Medical services that may require prior authorization include general surgeries and some in-office tests and procedures. Several factors determine whether medical services are approved or denied, including medical necessity and cost. If you cannot obtain prior authorization due to a medical emergency, the doctor or hospital caring for you must typically notify your health insurance company within 24 hours of your care or admission.
A provider refers to the doctor or hospital that cared for you.
The provider charge is the amount your doctor or hospital charged for the medical services they provided.
Provider-based billing is the “professional fee” (also known as a physician fee) that is sometimes listed on medical bills. Health care organizations that use provider-based billing systems charge fees for physician services separate from hospital or facility fees.