Understanding Your Insurance

Q. What is a deductible?

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A deductible is a specified amount of money that patients must pay out of pocket before an insurance company pays a claim. For example, if you have a $500 deductible, you will be responsible for this $500 out of pocket expense until this has been satisfied. Depending on your plan, your deductible may be reached from claims submitted by multiple providers (i.e. x-ray visit, hospital, or another specialist).

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Q. What is a copayment?

A copayment is a specified amount that must be paid for a service covered under a benefit plan. Copayments are collected at the time of service.

Q. What is co-insurance?

Co-insurance is a designated percentage that the insurance carrier carves out of the contractual payment; the patient or insured is responsible for the co-insurance payments. For example, if the insurance plan has a 10% coinsurance amount and the plan allows $100 per visit, total patient responsibility will be $10 per visit (10% of $100). Patients that have a co-insurance amount will be balance billed and expected to make payments for services until their balance has been satisfied.

Q: What is an out-of-pocket maximum?

An out-of-pocket maximum is the maximum a patient will have to pay for a covered service in a plan year. This can be a combination of deductible, co-insurance, and copayment amounts that have been paid for in network services. Once the out-pocket-maximum has been met, the insurance carrier will pay 100% of the costs of covered benefits.

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Q. I have received an Explanation of Benefits from my insurance carrier, now what?

Understanding the Explanation of Benefits (EOB) can be difficult; we are here to help! An EOB is a statement from the insurance carrier providing an overview of the cost for the services rendered. The EOB shows the amount billed to the insurance carrier and outstanding patient responsibility. Below we have broken down each column to assist you in understanding the statement.

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Date of Service: This is the date of service you were seen.

CPT: Codes for the services rendered during your PT or OT visit.

Billed Amount: This is the amount we billed your insurance carrier for the service rendered.

Allowed Amount: This is the amount your insurance carrier has allowed for the service rendered.

Paid Amount: This is the amount your insurance carrier has paid less any patient responsibility for the specified date of service.

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Adjustment: This amount is a reduction or write-off based on the billed amount and allowed amount. This adjustment is based on the contract between Carlisle Place Physical and Occupational Therapy and your insurance carrier. Please note, you are not responsible to pay the adjustment amount.

Copay, Deductible, and Co-insurance: This is the amount you are responsible for paying.

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