It is your responsibility as the plan member to challenge or appeal a Coverage Determination.ĭeductible is the dollar amount you must pay toward your covered healthcare expenses before your insurance plan begins to pay its share.Ĭopay (or Copayment) is the fixed dollar amount of your covered healthcare expenses for which you are responsible. If your insurer does not pay for any or all of the cost of the medical services you receive, you will remain personally liable for the unpaid balance of those services. Aspirus is not responsible for the Coverage Determination made by your insurer. Not all plans pay for the same services in the same way. Facility Fees are typically itemized and individually charged on bills that you receive, but Facility Fees may be bundled together for the purpose of your estimate.Ĭoverage Determination is the decision made by your insurer that a medical service is covered under the terms of your policy with them, and what amount you and your insurer will each have to pay for a medical service. These resources may include the use of the room and associated utilities, nursing or clerical time, the services of non-physician staff members like imaging and lab technicians and supplies or equipment. Facility Fees represent the charges for the resources involved in providing care to you. It is separate and distinct from the Professional Fee of the provider (such as a Physician, Nurse Practitioner or Physician Assistant). If your provider is independent with privileges to practice at Aspirus (such as providers from Radiology, ENT, GI or Surgical Associates), the provider will bill you separately for the Professional Fee.įacility Fee is a charge for the services of the Hospital or Clinic. Aspirus will bill you a Professional Fee when your provider is an Aspirus hospital or clinic employee or we have an agreement to manage his/her professional billing. Imaging tests commonly have Professional Fees since a radiologist reviews the images and provides his/her professional interpretation of the results. It is separate and distinct from the Facility Fee. Professional fee is a charge for the services of a healthcare provider such as a Physician, Nurse Practitioner or Physician Assistant. Receiving care from an Out-of-Network healthcare provider can mean your insurance plan will not cover some or all the costs of service and you will be responsible for any unpaid balance. Your health plan may be designed without any preferred network. Out-of-Network or Non-Participating is when your Aspirus provider is not part of your health plan’s preferred network of physicians and healthcare facilities. The amount you pay is usually lower when you receive care from a participating provider. In-Network or Participating is when your Aspirus provider is part of your health plan’s preferred network of physicians and healthcare facilities. Aspirus Network Business Health For Providers Foundations Medical Library Volunteers Student Programs Family Med Residency Program Pharmacy Residency Program Administrative Fellowship Program.
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