Insurance Questions and Terminology

Frequently asked Questions

You may find yourself trying to maneuver through the world of insurance and have heard or seen terms or abbreviations you are not familiar with. You are in luck, this will help fill you in on the most commonly used terms and abbreviations. We here at Cornerstone want to make the world of insurance as simple as possible for our families. There is enough on your plate to handle and deal with from day to day, so insurance should not be an added stress.

To begin, let’s identify terms seen on a regular basis, and if there are any you have questions about, please contact us so we might clear up any confusions or provide you with the correct meaning.

Authorization – an act of approval for services/treatment rendered. They are based on medical necessity and not always a guarantee of payment.

Benefits – your healthcare services or items that your insurance will cover based on which plan you have chosen.

Claim – a request for payment of services or treatment, submitted by the provider.

Coordination of Benefits – the way to decide which insurance is paying for what when an individual has more than one insurance plan. (In other words, who pays what and when?)

Health Insurance Marketplace – this is a resource for families/individuals to find information regarding their health care options. Each state may run their Marketplace somewhat different, here in Indiana our Marketplace options are state run and assist low income families in finding the best fit for their situation.

In Network – this means a health care provider has signed an agreement with your insurance and has agreed to render care/treatment for a set payment amount, which is at a reduced rate compared to private insurances.

Medicaid – a federally and state funded health insurance for those requiring financial help/assistance. Each state may have several different options to choose from, the names and benefits will vary depending on which option/plan you or your child has.

Medically Necessary – services that are used to help determine an illness, injury, condition and/or the symptoms that meet a certain accepted standard of medicine. (We have to prove treatment is medically necessary in order for insurances to grant authorizations)

Network – this is the larger group of providers that are contracted with your insurance plan to provide services. (There are in and out of network providers)

Out of Network – this is when you choose to go to a provider that is not contracted with your insurance.

Typically, you will pay a higher out of pocket rate than if you had chosen an In Network provider.

Prior Authorizations – an approval that must be requested before any service or treatment can occur.

It is the responsibility of your provider to obtain all information necessary in order to secure a prior authorization.

Referral – a written request from your primary health care provider to a specialist. This request will outline why a specialist is needed. Many insurances ask that a referral be submitted before the member seeks out specialized care.

Secondary Payer – an insurance policy that pays out after the primary plan has either denied or matched their benefits. Secondary is used only after the primary refuses to pay claims, or when the primary insurance does not cover all services.

Treatment Plan – a written document that provides goals, achievement and what needs to be worked on through on going therapy. (The insurance requires us to submit a treatment plan each time with ask for authorizations.) It allows them to see the progress of each child.

Abbreviations:

AIMS –Audit Information Management Services (This is soon to be replaced with a new program)

DOS – Date of Service

IHCP – Indiana Health Coverage Programs

This is only a small list of insurance terms, abbreviations and acronyms. If you have heard other terms or want more clarification on certain words, please don’t hesitate to ask for our assistance. Insurance doesn’t have to be stressful or scary — we want to make sure it is as easy as possible for everyone involved.

Who to ask?

Maybe you aren’t sure who to turn to when you have questions, so you just ask the first person available. Cornerstone is lucky enough to have a very talented insurance department. The best part of being part of the Cornerstone family is that we are able to do all of our own insurance billing, claims and authorizations in-house. Cornerstone doesn’t outsource their business, therefore, you are receiving the best possible attention to your insurance needs.

Jackie – has been with Cornerstone for almost a year, she brought with her, years of experience as a teacher, and medical coder. Jackie is not only a Certified Medical Coder, she is a valuable member of the Cornerstone family, and while she might not be part of the therapy staff, she has made a point of sharing her love of teaching by always being available to the children that visit the insurance office. You might have spoken to Jackie on the phone if you’ve called in a sick child, had questions about receiving a bill or notification in the mail or called the center with other issues or concerns. She is always willing to assist in any way possible, so if you have those questions about bills from the insurance carriers, you can always ask to speak to Jackie.

Beth – has been with Cornerstone for 1 ½ years, she is also a medical biller. Prior to joining the Cornerstone family, Beth worked as an EMT, bringing with her a passion for working with children, doing what is in their best interest and is always open to have them visit her desk throughout the day. Beth is a vital part of our team, always willing to jump right in to help out her fellow co-workers. She knows how important each family is to Cornerstone, and is a friendly voice on the phone when you call with questions. Just like Jackie, if you have questions regarding bills from the insurance carriers, please feel free to give Beth a call.

Rebecca – while new to Cornerstone, she has seven years of experience working for Medicaid. She is knowledgeable in the different delivery systems for the state of Indiana. She also brings with her, years of experience working in the behavioral health field. (Teaching, case management, therapy) She is now responsible for obtaining the authorizations for each child attending Cornerstone, as well as making sure Cornerstone is up to date on Medicaid requirements. If you have received forms you thought you had already signed, chances are, Rebecca has gone through the files and noticed missing documentations. She will be the one responsible for keeping your child’s record in order. And while she is not out in the building working one on one with the children, she and the rest of the insurance department are behind the scenes, making sure each child has the appropriate insurance coverage and authorizations in place to stay at Cornerstone. If you ever have concerns or questions regarding the world of insurance, please call Rebecca, she is always happy to talk to a parent.

These ladies work hard every day to help Cornerstone families maneuver through the world of insurance without being stressed. At Cornerstone, we understand it takes a village to make the difference in one life. By doing our jobs, we assure the families have little to worry about when it comes to the world of insurance. We know each family is already dealing with many stressors, and we make it our goal to make the insurance side of things run smoothly. This way families and therapist are able to focus their energies where it is needed the most — the children of Cornerstone.

Until next time, remember we are here to help you and please call if you have questions.

Last updated by Morgan McClellan at February 18, 2016.