Insurance Resources

Kids First Team Member
1 day ago
4 min read

With changes coming to healthcare coverage and a new year approaching, we thought it would be helpful to share the following resources about how to read your child’s medical bills and insurance forms from healthychildren.com.

Sorting through your child's medical bills or health insurance forms can be a challenge.

How can you tell how much, who, and what the bill is for? And what's the difference between an explanation of benefits (EOB) and a bill? What do all the charges mean? How much of it is covered by insurance? What do you owe?

Read on to learn about phrases used on medical bills and forms you receive from health insurance, doctors, and hospitals. (For information about types of insurance and choosing a plan, see "Tips for Choosing Health Insurance for Your Family.")

Explanation of benefits (EOB)

An explanation of benefits (EOB) is provided to you by your health insurance plan. It describes what the health insurance plan will cover and what you will pay when you get the bill from the doctor. In general, here are some of the items listed.

Your child's name (the patient) and the name of their health plan
Who provided your child's care and when
A description of the service (for example, medical visit or lab test)
A reference number (claim number)
The total charge for the visit. This includes:
- The amount billed by the doctor (provider charges)
- The amount that the doctor will be paid (allowed charges)
- How much is paid by the health plan (paid by the insurer) to the doctor
- What you owe (patient balance) after the health plan has paid

An EOB is not a bill. Keep the EOB and compare it to the bills to make sure there are no billing errors. (See an example of an EOB here.)

Medical bill

The medical bill(s) comes from the provider or hospital. There could be more than one bill for the service. For example, you may get a bill from the doctor and one from the laboratory. Here are some of the items on a medical bill.

Your name (or your child's name) and address
Name and address of the doctor or hospital
Account number—use this number to pay the bill
Dates of service
Description of services
Costs:
- Total charge: The full price for services.
- Allowed amount: The maximum that the health insurance plan will pay for the service. It may also be listed as an eligible expense, payment allowance, or negotiated rate.
- Adjustment: The amount that your doctor or the hospital subtracts from the total charges. They subtract it because they have agreed on a discount or lower amount with the health insurance plan.
- Health insurance payment: The amount your insurance paid or will pay after you pay.
- Patient payment: Any amount you already paid, such as the copayment.
- Balance due/patient responsibility: The amount you owe.
How to pay: Information about how to pay the bill by mail, online, or over the phone is usually at the top or bottom of the bill or on a payment slip.

People who do not have health insurance usually have to pay the full amount on the bill. You can ask for a good faith estimate of expected charges ahead of time.

Out-of-pocket costs/maximum

Health insurance plans require us to pay some of the cost of services. This is known as an out-of-pocket cost. Examples of out-of-pocket costs are:

deductibles
coinsurance
copayments
other medical expenses not covered by your plan

Your plan may also have an absolute maximum amount that you would pay within a plan year (out-of-pocket maximum). Once you have paid the maximum, your plan will pay its share for the rest of the plan year. The Affordable Care Act requires most private health insurance plans to pay for preventive services without out-of-pocket costs.

Copay

A copay is an amount that you pay for a health service at the time of your visit. Usually, the copay information is printed on your health insurance card. There are different copay amounts for each type of visit. For example, your insurance may have separate copay amounts for:

Primary care visit
Specialist visit
Emergency department visit
Prescriptions
Laboratory tests

Deductible

A deductible is what you pay for health services (such as doctor, emergency department, or hospital visits and tests) before your health insurance begins to pay. A person with a $500 deductible would pay the full amount for each visit or service until they have paid $500 in total. After that, insurance will begin to pay. The deductible starts over every plan year.

Coinsurance

After you've paid your deductible, coinsurance is a percentage that you pay for a service that is covered by your health insurance plan. For example, if your insurance plan pays 90% of the cost of the service, the coinsurance amount that you owe is 10%.

In-network/out-of-network provider

Health insurance plans have contracts with specific doctors (in-network providers) who are listed in the health plan directory. The insurance plan prefers that you go to someone who is in the network. The cost is usually less than the cost of someone who is not in the network (out-of-network provider). Some insurance plans will only cover out-of-network care if you have a referral or prior authorization. Learn more here.

Have questions about other terms like Current Procedural Terminology (CPT) codes, Denial of payment, surprise medical bill, prior authorization, or letter of medical necessity? VISIT THIS LINK.

Have specific questions about your Kids First Pediatrics billing? Let us know: Raleigh (919) 250-3478, Clayton: (919) 267- 1499.