Common Insurance Terms Defined

We prioritize transparency with patients & in an effort to clarify the confusion with insurance coverage, we have included definitions & examples of Common Insurance Terms to ensure patients & providers are on the same page & possess a better understanding of the complexities in insurance coverage.

In-Network vs. Out-of-Network (OON)

If a provider is in-network with an insurance, they are able to see insured PPO members at a contracted fee-for-service rate (based on the insurance plan’s “Allowed amounts” for covered services). This does not apply to any HMO plans as they must see providers within the narrow HMO group.
Out-of-network (OON) providers are not subject to the same contractual rates as an in-network provider. If you decide to receive care from an OON provider, you will be responsible for the full bill at the OON provider’s fee-for-service rates.

Co-pay for each Specialist Office Visit @ Seaside Audiology

The amount owed for an office visit with a particular provider type. For Seaside Audiology, you will owe a Specialist Copay @ the TOS for each office visit. The specialist copay is typically listed on your insurance card.

Deductible (In-network/annual, OON / Annual, Specialist Deductible, etc)

The Deductible is the designated out-of-pocket (OOP) amount your insurance requires you to pay toward medical care * BEFORE * your insurance begins to cover any portion of your medical bills (at the cost-sharing % Benefit coverage terms of your specific plan). For example, if you have a $3,000 deductible, your insurance requires you to pay the full $3,000 Deductible OOP in full before they will begin to share the cost of any portion of your care. Note: insurances typically have an in-network annual deductible, OON annual deductible, and sometimes a separate specialist deductible (for any specialist medical care received).

Co-Insurance (“Percentage Benefit” ) & Sharing the Cost-Sharing of Care Received between patients & insurance

Your insurance plan typically has a “Percentage Benefit” which describes how the cost for your care will be shared. For example, plans with an 80/20 percentage benefit describe sharing the billed amount for your care (even after your OOP deductible has been met), with 80% paid by insurance & 20% designated as OOP patient responsibility (PR), payable directly to the provider. In this example, this means that even though you may have met your deductible, your insurance will still require you to pay 20% of the billed amount for care received based on your plan’s cost-sharing % Percent Benefit / Coverage.
** Co-insurance / Cost-sharing terms of your insurance plan usually kicks in after you have met your OOP deductible, but coinsurance may still be assigned to you prior to meeting your deductible (see the insurance Explanation of Benefits (EOB) for your insurances’ designation of your patient responsibility (PR) which includes coinsurance/deductible/additional copays for certain services provided.

Out-of-Pocket (OOP) Maximum - OOP Max or “Stop Loss”

The maximum amount of OOP expenditure you must pay toward medical services over a certain period of time (your insurance will typically cover the majority of the billed amount for your care once the OOP maximum is reached). Typically, the OOP max / Stop Loss is designated between $11,500- $19,500 depending on your specific insurance plan, carrier, etc. This means once you have paid OOP and met the designated OOP max / Stop Loss amount, your insurance will begin to cover the majority of the cost of your medical services.

Prior Authorizations / Pre-Certifications

Certain insurance plans require prior authorization (prior auths) / Precertification (pre-certs) for certain types of medical services, facilities, or treatment. If a prior auth/pre-cert is required but Not obtained prior to receiving care, your insurance will not cover the services provided and you would be responsible.
Obtaining a Prior Auth/Pre-Cert does NOT always guarantee insurance payment for care. Patients are responsible for obtaining any required prior auths /pre-certs for their medical care.

In-Network* PPO Plans

Blue Shield of California (BCBS) / BCBS FEP Plans -see note for out-of-state BCBS plans
Medicare Advantage PPO (i.e. Anthem Medicare Advantage)/Medicare + Supplement PPO
TriWest Healthcare Alliance (TW)
VA Community Care Network (CNN) for Active & Retired Veterans
Workers Compensation (WC) - pending authorization and approval of WC case
ILWU-PMA Benefit Plans for Active & Retired Longshore Workers of the West Coast’
United Medical Resources (UMR)

In-Network PPO Coverage Notes:

Per our TOS Policy, your estimated OOP Responsibility (including Specialty Copays, UNMET Deductible(s) & coinsurance (if applicable) will need to be collected @ the TOS at Check-in before any care is provided

We do NOT accept any HMO plans, Narrow Network or Limited Benefit Plans (Regardless of Network status)
Out-of-State (Non-California) BCBS plans: We respectfully require a precertification letter of coverage & guaranteed in-network payment for care provided to you by Seaside Audiology *PRIOR TO* scheduling those with out-of-state BCBS plans
BCBS is NOT the same as Anthem Blue Cross (BC) - we are NOT in network with commercial (Non-Medicare) Anthem BC plans
Prior Referral Authorizations are required for those insured with TriWest, VA CCN and ILWU-PMA plans

Out-of-Network (OON) Plans*

All HMO plans (including any HMO In-network plans)
Aetna
Anthem Blue Cross (BC) - we are OON with Commercial (Non-Medicare) Anthem BC plans
Cal-Optima (Medi-Cal / Medicaid)
Cigna
Humana
Kaiser
Monarch
TriCare East
SCAN
UnitedHealthCare (UHC) - we are OON with many Commercial (Non-Medicare) UHC plans
Third Party / Managed Care Plans ( Epic, HCS, etc)
All Limited Benefit Plans (LBNs) / Narrow Network Plans ** -- we are OON with all "Personal Choice," Select PPO, Select Choice, "Independent Blue," Multiplan, Managed Care, etc

* For OON patients: Upon request, we will provide you with an itemized invoice for services rendered to submit to insurance (this is a process to be exclusively mediated between patients and their insurance companies). To clarify, patients must work directly with their insurance(s) when submitting itemized invoices for OON care provided at Seaside Audiology.

** We do NOT accept Narrow Network & Limited Benefit Plans (Regardless of Network status)

Narrow Network & Limited Benefit Plans (LBPs): We are OON with ALL Narrow Network & LBPs.
These plans are not always easy to identify, and the cards these plans give to their members are often confusing.
These plans go by many names, including, but not limited to: Independent Choice, Personal Choice (i.e. Independent Blue), Select PPO, Select Choice, Multiplan, Cost-Sharing plan, Health-sharing plan, Practitioner-only plan, physician-only plan
These plans offer very limited coverage for a very limited # of services with essentially no coverage for specialist care. In other words, they pay very little for very few types of Non-specialty services.
LBPs also often use a practice called “unilateral pricing,” which means the plan tries to dictate how much the provider should be paid for health services to their members, even though the plan does NOT have a contract with the provider.
Typically, if your card has any of the following 3-letter prefixes, you have a Narrow Network/LBN plan:
FXB, LII, JBE, JQL, JQM, JQN, JQO, JQP, JQR, JQU, JQY, VXB, VXD, YZC.
If your plan utilizes a unilateral pricing practice or if your plan tells you that you can go to any hospital you want, you may have a Narrow Network or LBP.
Many of the cards for these types of plans state something like “acceptance of this card indicates acceptance of the plan’s benefit as payment in full,” “this plan pays for all services at 40% of the Medicare allowable amount,” or even “accepting this card waives the provider’s right to bill the patient.”
If your card has any of the above phrases on it, you likely have a Narrow Network or LBN:
Not all Narrow Network & LBP are alike and even if your card doesn’t include any of the wording mentioned, you may still have a Narrow Network or LBP.

Navigating insurance coverage can be confusing & time-consuming, so as a courtesy, our medical billers will verify your insurance coverage (deductible, coinsurance, copays, etc) as part of the New Patient Intake Process. Our goal is to provide you with an accurate estimate of any out-of-pocket (OOP) patient responsibility (PR) you may owe at the Time of Service (TOS) in advance, in order to help you financially plan for your care.
New Patient Intake Process: For new patients wanting to use their in-network PPO insurance, our medical billers will verify your coverage to check for any out-of-pocket (OOP) responsibility you may owe at the time of service (TOS). The new patient intake process & acknowledgement of PR must be completed prior to scheduling an appointment.
Acknowledgement of Patient Responsibility (PR): As soon as your insurance has been verified, we will contact you with an estimate of any OOP you may owe at the time of service ( TOS ) for the visit ( if any). Your estimated OOP responsibility is based on your specific plan deductible(s), copay, coinsurance, cost-sharing terms, plan exclusions, non-covered benefits, etc.
Once you acknowledge / confirm your understanding of the estimated OOP responsibility to be collected at the TOS, we will be contact you to schedule a new appointment (*this depends on scheduling availability)
Time of Service (TOS) Policy: Due to the high demand & limited availability for our specialty care & advanced treatment services, we have implemented a TOS Policy which requires any OOP responsibility to be paid at check-in for your appointment before any medical care is provided.
The OOP responsibility due at the TOS is based on your specific deductibles, copays, coinsurance, cost-sharing terms, plan limitations & any excluded/non-covered services. For your convenience, we accept Cash, Checks, Major debit/credit cards (Visa, Mastercard, Discover, American Express).
For those with financial hardship, we offer no-interest payment plans pending approval of a financial hardship application.
We want to clarify that it is ultimately a patient’s responsibility to understand/verify their insurance coverage, plan exclusions, coinsurance, etc & to be aware of any OOP costs / deductibles that will apply for specialty healthcare received at Seaside Audiology.
Prior to your visit, we recommend that ALL patients contact their insurance carrier (refer to the phone # on the back of your insurance card) to verify your individual in-network coverage, eligibility, deductibles, coinsurance, copays, eligibility, any insurance-specific requirements (prior authorizations, precertification, referrals), limitations/exclusions, Non-covered services, and any other potential OOP costs that may apply to your visit.
Keep in mind we provide an estimate based on the insurance information available to our billing department, and that your insurance may assign a different amount for your OOP responsibility once claims are processed - Please review your Explanation of Benefits (EOB) for details once the claim(s) have been finalized.

ALL PATIENTS: We reserve the right to cancel / reschedule your visit if either a) incomplete/incorrect insurance information was provided during the new patient intake process, or b) if a patient does not commit to paying their owed OOP responsibility prior to their visit per our TOS policy. We will make every effort to reach you before your scheduled visit to discuss any issues that warrant potential cancellation of your visit.

Common Insurance Terms Defined

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Common Insurance Terms Defined

In-Network vs. Out-of-Network (OON)

​

Co-pay for each Specialist Office Visit @ Seaside Audiology

The amount owed for an office visit with a particular provider type. For Seaside Audiology, you will owe a Specialist Copay @ the TOS for each office visit. The specialist copay is typically listed on your insurance card.

​

Deductible (In-network/annual, OON / Annual, Specialist Deductible, etc)

​​

Co-Insurance (“Percentage Benefit” ) & Sharing the Cost-Sharing of Care Received between patients & insurance

​

Out-of-Pocket (OOP) Maximum - OOP Max or “Stop Loss”

Prior Authorizations / Pre-Certifications

​

In-Network* PPO Plans ​

Blue Shield of California (BCBS) / BCBS FEP Plans -see note for out-of-state BCBS plans

Medicare Advantage PPO (i.e. Anthem Medicare Advantage)/Medicare + Supplement PPO

TriWest Healthcare Alliance (TW)

VA Community Care Network (CNN) for Active & Retired Veterans

Workers Compensation (WC) - pending authorization and approval of WC case

ILWU-PMA Benefit Plans for Active & Retired Longshore Workers of the West Coast’

United Medical Resources (UMR)

​

In-Network PPO Coverage Notes:

Per our TOS Policy, your estimated OOP Responsibility (including Specialty Copays, UNMET Deductible(s) & coinsurance (if applicable) will need to be collected @ the TOS at Check-in before any care is provided​​

We do NOT accept any HMO plans, Narrow Network or Limited Benefit Plans (Regardless of Network status)

Out-of-State (Non-California) BCBS plans: We respectfully require a precertification letter of coverage & guaranteed in-network payment for care provided to you by Seaside Audiology *PRIOR TO* scheduling those with out-of-state BCBS plans

BCBS is NOT the same as Anthem Blue Cross (BC) - we are NOT in network with commercial (Non-Medicare) Anthem BC plans

Prior Referral Authorizations are required for those insured with TriWest, VA CCN and ILWU-PMA plans

​

Out-of-Network (OON) Plans*

All HMO plans (including any HMO In-network plans)

Aetna

Anthem Blue Cross (BC) - we are OON with Commercial (Non-Medicare) Anthem BC plans

Cal-Optima (Medi-Cal / Medicaid)

Cigna

Humana

Kaiser

Monarch

TriCare East

SCAN

UnitedHealthCare (UHC) - we are OON with many Commercial (Non-Medicare) UHC plans

Third Party / Managed Care Plans ( Epic, HCS, etc)

All Limited Benefit Plans (LBNs) / Narrow Network Plans ** -- we are OON with all "Personal Choice," Select PPO, Select Choice, "Independent Blue," Multiplan, Managed Care, etc

​

​

** We do NOT accept Narrow Network & Limited Benefit Plans (Regardless of Network status)

Narrow Network & Limited Benefit Plans (LBPs): We are OON with ALL Narrow Network & LBPs.

These plans are not always easy to identify, and the cards these plans give to their members are often confusing.

These plans go by many names, including, but not limited to: Independent Choice, Personal Choice (i.e. Independent Blue), Select PPO, Select Choice, Multiplan, Cost-Sharing plan, Health-sharing plan, Practitioner-only plan, physician-only plan

These plans offer very limited coverage for a very limited # of services with essentially no coverage for specialist care. In other words, they pay very little for very few types of Non-specialty services.

LBPs also often use a practice called “unilateral pricing,” which means the plan tries to dictate how much the provider should be paid for health services to their members, even though the plan does NOT have a contract with the provider.

Typically, if your card has any of the following 3-letter prefixes, you have a Narrow Network/LBN plan:

FXB, LII, JBE, JQL, JQM, JQN, JQO, JQP, JQR, JQU, JQY, VXB, VXD, YZC.

If your plan utilizes a unilateral pricing practice or if your plan tells you that you can go to any hospital you want, you may have a Narrow Network or LBP.

Not all Narrow Network & LBP are alike and even if your card doesn’t include any of the wording mentioned, you may still have a Narrow Network or LBP.​​​​

Once you acknowledge / confirm your understanding of the estimated OOP responsibility to be collected at the TOS, we will be contact you to schedule a new appointment (*this depends on scheduling availability)​

For those with financial hardship, we offer no-interest payment plans pending approval of a financial hardship application.

We want to clarify that it is ultimately a patient’s responsibility to understand/verify their insurance coverage, plan exclusions, coinsurance, etc & to be aware of any OOP costs / deductibles that will apply for specialty healthcare received at Seaside Audiology.

​

​

In-Network* PPO Plans

Per our TOS Policy, your estimated OOP Responsibility (including Specialty Copays, UNMET Deductible(s) & coinsurance (if applicable) will need to be collected @ the TOS at Check-in before any care is provided

Out-of-State (Non-California) BCBS plans: We respectfully require a precertification letter of coverage & guaranteed in-network payment for care provided to you by Seaside Audiology PRIOR TO scheduling those with out-of-state BCBS plans

Not all Narrow Network & LBP are alike and even if your card doesn’t include any of the wording mentioned, you may still have a Narrow Network or LBP.

Once you acknowledge / confirm your understanding of the estimated OOP responsibility to be collected at the TOS, we will be contact you to schedule a new appointment (*this depends on scheduling availability)