Common Insurance Terminology

Referral

• A referral is an authorization from your insurance company for you to see a specialist. A referral has to be requested by your primary care doctor and submitted to your insurance company. Referrals are not always required for you to see a specialist, it depends on your insurance plan. Some major insurance plans that require referrals are Secure Horizons, Cigna HMO plans, Aetna HMO plans and New West Physicians Group. Please check with your insurance to see if a referral is required.

Co-Payment

• A copayment is an amount that your insurance has assigned you to pay when you have a medical appointment. The amount of your co-payment may be different depending on what kind of appointment you have. All co-payments through Denver Vein Center will be considered a “specialist” visit. Your co-payment amounts are listed on your insurance card, and are due at the time you have your appointment.

Deductible

• Your deductible is the number of expenses set forth by the insurance plan that you have to pay out of pocket before your insurance company pays the claim. Deductible amounts differ with every insurance plan. Please call your insurance if you are unsure of your deductible.

Co-Insurance

• After you meet your deductible, most plans require you to pay a co-insurance. The co-insurance amount is a set amount they pay after your deductible has been applied. The insurance will pay a percentage and the rest is the patient balance. For example, if you have a 90/10 plan, your insurance will pay 90% of the claim after your deductible and you will be responsible for 10%.

Out of Pocket Maximum or Cost Sharing Cap

• This is an amount the insurance company has set as your total out of your pocket costs per year. This amount does not usually include your deductible or co-payments but does include your co-insurance payments. After you reach your out of pocket maximum, your insurance company covers claims at 100%, so you no longer have to pay co-insurance amounts.

In Network Benefits

• Choosing an in-network provider lowers your out-of-pocket expenses. In-network providers and those who “participate” with your insurance have agreed to provide discounted fees for their services to members. Providers who “participate” with your insurance company will accept the insurance payment as payment in full. You are only responsible for your in-network deductible, co-insurance (if any) and the co-payments listed in your specific plan.

Out of Network Benefits

• Many insurance companies offer out of network benefits for providers that do not participate in their plan. Usually, the out of pocket cost is higher. Check with your insurance provider for more details.