Allowed amount
The amount we agree to accept as payment in full through our contracts with different payers.

Certificate of credible coverage
A document from your previous insurance carrier which verifies dates of coverage. Your new policy will require this document in order to waive/reduce your pre-existing condition period.

Co-insurance
A co-sharing agreement between the patient and the insurance, where the patient pays a specific percentage out-of-pocket at the time of service, with the insurance paying the remaining percentage.

Contracted adjustment
The difference between our charged amount and maximum allowed amount, which is adjusted off according to our contracts with different payers.

Coordination of benefits (COB)
The coordination of payment between two or more insurance carriers who insure the same patient.

Co-pay
A specified out-of-pocket expense that is due by the patient at the time of service. The insurance pays the remaining amount. A co-pay is usually a specific dollar amount, dependant on the type of service provided.

Deductible
A clause in an insurance policy that exempts the insurer from paying an initial specified amount in the event that the insured sustains a loss (The Free Dictionary by Farlex).

EDI edit
An electronic rejection of a submitted claim, prior to the claim entering the payer’s system. Claims are usually rejected for incomplete/invalid information, or because the patient can’t be found in the system.

Electronic claims
Claims that are submitted in an electronic format, rather than on paper.

Global period
A period of time immediately prior to or after a surgical procedure in which all routine follow-up care is included in the original charge amount. Global periods vary depending on the procedure. Most global periods for minor surgical procedures are between 0-10 days (ie. lacerations, wart removal, circumcision, etc.).

Inclusive
Included in or incidental to another procedure/service.

Maximum allowable
The amount we agree to accept as payment in full through our contracts with different payers.

Maximum benefit
A cap on certain types of service (such as preventive care) that, once reached, means there are no further benefits available for that type of service for the remainder of the benefit period (usually, but not always, the calendar year).

Non-covered service
A service that is not covered under the provisions of your policy.

Payer(s)
An insurance company.

Pre-existing condition
A condition that is considered chronic or requiring continuous treatment that was diagnosed prior to coverage with your insurance company. If there has been no significant break in coverage, a pre-exising period can be waived with a Certificate of Credible Coverage from your previous insurance company(ies).

RBRVS
Resource-Based Relative Value Scale. This is a national scale that gives value to the different services provided by physicians. It is off of this scale that our charges are based.

Self-pay
Classified as anyone without insurance, or whose insurance does not cover routine medical care (ie. catastrophic or major medical coverage only).


Want pediatric news, kid-friendly recipes and parenting tips?
Sign up for our patient parent newsletter: