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Insurance Terms to Know

Part of what makes insurance tricky is all the specialized language. Here are some of the key words and phrases to know when you’re looking at your plan:

Allowable amount
The maximum cost that your insurance company has determined is appropriate for a specific service. Out-of-network reimbursement is based on the allowable amount for the service your child gets, rather than the actual amount that your provider charges.

Copay
The amount you have to pay each time your child gets care. The copay is a portion about the total cost of the care. For example, if your child’s doctor charges you $100 and your copay is $25, you pay $25 and your insurance company pays $75. For out-of-network providers, this cost is sometimes called coinsurance. Coinsurance is usually a percentage of the total cost of service rather than a dollar amount.

CPT
CPT stands for “current procedural terminology” It is a series of numbers linked to a specific treatment, like an individual psychotherapy session or a medication management visit with a psychiatrist. Insurance companies use CPT codes to guide reimbursement for treatment.

Deductible
The amount you have to pay for your child’s health care each year before your insurance company will start paying for care.

In-network
In-network providers have a contract with your insurance company. The insurance company pays them directly for providing care.

NPI
NPI stands for “national provider identifier.” It is a unique number used to identify a specific healthcare provider.

Out-of-network
Out-of-network providers do not have a contract with your insurance company. If a provider tells you that they don’t take your insurance, that means they are out of network. Your insurance plan may reimburse you for part of the cost of seeing an out-of-network provider, but they do not pay for care directly.

Pre-approval
A pre-approval is an agreement with your insurance company that they will pay for a specific service. Some companies require you to get pre-approval before getting care in order for the company to pay for care. This is sometimes called pre-authorization.

Premium
The price you pay every month for your insurance coverage.

Provider
Someone who provides health or mental health treatment. A provider for children’s mental health care might be a psychiatrist, psychologist, social worker or other professional.

Referral
A note from a doctor saying that it is medically necessary to see another doctor. For example, your child’s pediatrician might make a referral to a psychiatrist if your child needs more specialized care. Some insurance companies require a referral in order to pay for mental health care.

Superbill 
A document that includes details of all the care your child received during a certain period. If you are using out-of-network benefits, your provider can give you a superbill to send to the insurance company with your claim for reimbursement. 

Return to Connect to Care for more information about getting kids help.