Commonly Used Insurance Terms

Referrals

Some insurance companies require referrals to a specialist, prior authorization for services, which facilities you can use for diagnostic tests, which drugs are preferred, etc. It is your responsibility to verify and comply with any insurance company requirements.

Authorizations

Some insurance companies require referrals to a specialist, prior authorization for services, which facilities you can use for diagnostic tests, which drugs are preferred, etc. It is your responsibility to verify and comply with any insurance company requirements.

Insurance

PDEC is a participating provider with most insurance plans, but please contact your insurer to verify that your specific plan allows you to see providers at our clinic. We will bill your insurance according to our contract terms with them. You are responsible for any co-pays, deductibles, non-covered services, or other charges not paid by insurance.

Deductible

The deductible refers to the amount of money that the insured would need to pay before any benefits from the health insurance policy can be used. This is a yearly amount so when the policy starts again, after about a year, the deductible resets. Some services, like doctor visits, may be available without meeting the deductible first. Usually, there are separate individual deductible amounts and total family deductible amounts.

Coinsurance

This is the percentage of treatment costs that is the insured individual’s responsibility. A common co-insurance split is 80/20. This means that the insurance company will pay 80% of the costs associated with treatment and the insured is required to pay the other 20%.

Co-Payments

A co-payment is a fixed dollar amount that a patient is required to pay at the time of service. It is usually required for regular doctor visits and when purchasing prescription medications.

Out Of Pocket (OOP) Maximums 

This is the maximum amount a patient would have to pay toward covered services during a benefit period. Generally, this is comprised of your deductible, copayments, and coinsurance, but it can vary by plan. Once the out of pocket is met, the plan will pay 100% of costs for the remainder of the benefit period.

Exclusions

Services your insurance policy will not cover. These cannot be appealed or disputed as they are written into the plan.

Health Maintenance Organization (HMO) 

A Health Maintenance Organization plan arranges care for patients. Coverage is limited to providers who are contracted within the network, and it is subject to referrals from a primary care provider. No benefits) will be offered for services outside the network (besides emergency).

Preferred Provider Organization (PPO)

A Preferred Provider Organization is a form of health plan offering more freedom to the patient. With this plan structure, you have the freedom to see the providers and facilities of your choice without referrals. However, this does not mean that your coverage will be the same at each location. There are still network restrictions on your benefits. An in-network provider will result in a higher benefit, whereas an out of network provider will mean a lower benefit.

Medicare

As participating providers with Medicare, we are required to bill Medicare directly for your services. Under present Medicare rules, we receive 80% of the amount Medicare allows after your deductible is met; you are responsible for the remaining 20% plus any deductible amount.

Patient Balances

You will be billed for any balances not paid by insurance. The balance is due when you receive your first statement unless special arrangements have been made with our office. Our Patient Accounts department is always available to talk with you about your account and assist you with payment options. We accept Visa, MasterCard, American Express, and Discover. 

To contact our Patient Accounts Department please call 503-274-4808 or you can pay your statement balance via our company website or your patient portal account. 

Our phone hours are Monday – Friday 8:30 am – 4:30 pm, closed for lunch from 12:15 pm – 1:30 pm. For our patients that are speech or hearing impaired, please click on the button below for assistance in contacting us.