Authorization: Similar to pre-authorization, but may also refer to a referral needed from a primary care physician to see a specialist. Verification staff may need to confirm if an authorization is required for a specific service.

Benefits: The specific services or treatments covered by a patient's health insurance plan. Verification staff review the plan details to understand what services are covered and any limitations or exclusions.

Claims: A formal request for payment submitted to the insurance company by a healthcare provider for services rendered to a patient. Verification staff may need to gather information to ensure a claim is submitted accurately.

Claim Denial: A situation where the insurance company refuses to pay for a submitted claim. Verification staff may need to follow up on denied claims to understand the reason and potentially appeal the decision.

COB (Coordination of Benefits: When a patient has more than one health insurance plan, COB determines which plan is primary and pays first. Verification staff may need to understand COB rules if a patient has multiple insurance policies.

COB Payment Tracking: The process of tracking payments made by different insurance companies under COB rules to ensure the patient is not overbilled.

Copay (Copayment): A fixed dollar amount you pay for a covered medical service, like a doctor's visit or prescription medication. Unlike a deductible, a copay is typically paid at the time of service, often directly to the provider. Think of it like a set fee you pay for certain covered services.

Deductible: The amount of money you must pay out-of-pocket for covered medical services before your insurance plan starts sharing the cost. Think of it like a down payment you make on your healthcare expenses each year. Once you reach your deductible, your insurance plan typically kicks in and starts covering a portion of the remaining costs according to your plan benefits.

Eligibility: This refers to whether a patient is currently covered under a specific health insurance plan and has benefits in effect. Verification staff confirm a patient's eligibility to ensure the insurance plan will cover healthcare services.

EOB (Explanation of Benefits): A document you receive from your insurance company after a covered medical service is provided. This document explains the charges associated with the service, how much your insurance plan paid, and how much you are responsible for paying. Think of it as a receipt that details your portion of the bill after insurance has been applied.

EOB Review: The process of reviewing the Explanation of Benefits (EOB) document to ensure the insurance company covered services as expected and identify any discrepancies that might require clarification.

In-network: Refers to doctors, hospitals, and other healthcare providers who have contracted with your insurance company to provide services at a negotiated rate. These providers agree to accept specific rates from your insurance company for covered services. Using in-network providers generally results in lower out-of-pocket costs for you because your insurance plan has already negotiated a discounted price.

Maximum Out-of-Pocket (MOOP): The maximum amount you will have to pay out-of-pocket for covered medical services in a plan year after you've met your deductible. This includes deductibles, copays, and coinsurance. Once you reach your MOOP, your insurance plan typically covers 100% of allowed charges for covered services for the rest of the plan year.

Out-of-network: Refers to doctors, hospitals, and other healthcare providers who have not contracted with your insurance company. These providers do not have a pre-arranged agreement with your insurance plan on pricing. Using out-of-network providers typically results in higher out-of-pocket costs for you because your insurance plan may not cover as much of the service or may not cover it at all.

Pre-authorization (PA): Another term for pre-authorization, used to confirm if approval is needed from the insurance company before a specific service is performed. Verification staff obtain prior authorization to ensure coverage and avoid potential claim denials.

Premium: The regular monthly payment you make to your insurance company to maintain coverage under your health insurance plan. Think of it as your monthly subscription fee for having health insurance.

Prior Authorization: In some cases, your insurance company may require pre-authorization before covering certain medical services, such as surgery or hospitalization. This means you or your doctor needs to get approval from the insurance company before the service is performed. This helps the insurance company manage costs and ensure the service is medically necessary according to their plan guidelines.

Referral: A written order from a primary care physician for a patient to see a specialist. Verification staff may need to confirm if a referral is required and ensure it's valid.