Billing & Claims

Decode your medical bills and insurance paperwork — prior authorizations, formularies, and how to read an Explanation of Benefits.

11 Terms in This Topic

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EOB (Explanation of Benefits) →Prior Authorization →Appeal (Claim Denial) →

Jump to:A B C D E F M P S U

Appeal (Claim Denial)

A formal process to challenge your insurer's decision to deny a claim or service.

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Balance Billing

When an out-of-network provider bills you for the difference between their charge and your insurer's payment.

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Coordination of Benefits

Rules that determine which insurer pays first when you're covered by more than one health plan.

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Durable Medical Equipment (DME)

Reusable medical items — like wheelchairs, CPAP machines, and blood glucose monitors — covered by insurance.

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EOB (Explanation of Benefits)

A statement from your insurer explaining what was billed, covered, and what you owe.

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Formulary

Your insurance plan's list of covered prescription drugs, organized by cost tiers.

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Medical Necessity

The standard insurers use to determine whether a service is appropriate and required for your condition.

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Prior Authorization

Approval required from your insurer before receiving certain services or medications.

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Step Therapy

An insurer's requirement to try lower-cost medications before approving a more expensive drug.

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Surprise Billing (No Surprises Act)

Unexpected medical bills from out-of-network providers — now largely prohibited by the No Surprises Act.

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Utilization Review

An insurer's evaluation of whether a healthcare service is medically necessary and appropriate.

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Billing & Claims

11 Terms in This Topic

Appeal (Claim Denial)

Balance Billing

Coordination of Benefits

Durable Medical Equipment (DME)

EOB (Explanation of Benefits)

Formulary

Medical Necessity

Prior Authorization

Step Therapy

Surprise Billing (No Surprises Act)

Utilization Review

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