Insurance

Central Coast Audiology accepts most insurance programs such as Blue Cross, Blue Shield, United Healthcare and Aetna. We do accept Medicare, but as a sole insurance carrier Medicare does not cover hearing devices, but they do cover audiology diagnostic testing.

Many insurance plans today have hearing device benefits. On average, those insurance plans that cover hearing devices have a benefit that range from $100 per hearing device to $1000 per hearing device. Although every plan is different, the plans that have hearing device coverage also have a time limit of how often you may exercise the covered benefit. Most plans have an average time period of 24 months. If you are not sure if your plan covers hearing devices, make an appointment with our staff to look up these benefits.

Insurance Form HCFA1500 -

Please go to the link below and print and fill-out the following form:

List of Health Insurance Definitions:

Allowed Amount
Definition: The amount of the billed charge the insurance company deems is payable by the plan.

Ambulatory Care
Definition: Medical care on an out-patient basis, such as hospital outpatient clinics and ER Departments, physician's office and home health care are examples.

Ancillary Services
Definition: The name given to professional services such as laboratory tests and radiology exams.

Assignment of Benefits
Definition: The patient or guardian signs the Assignment of Benefits form so that the physician or medical provider will receive the insurance payment directly.

Authorization
Definition: If a physician wants to perform a surgery, order a medical supply, or refer the patient to a specialist an authorization and approval by the health plan is required.

Average Wholesale Price
Definition: This value is generally accepted as a standard measure of evaluating the cost of a particular medication.

Benefit Penalty
Definition: A method used by the insurance company to reduce payment on a claim when the patient or medical provider does not fulfill the rules of the health plan.

The Birthday Rule
Definition: A method of determining coordination of benefits under both parent's plans of medical insurance.

Bundling
Definition: A method by which the insurance company decides to combine payment for two or more medical services.

Capitation
Definition: A payment methodology in which the physician is paid a set dollar amount determined by a per member per month (pmpm) calculation to deliver medical services to a specified group of people.

Carve-out
Definition: Medical services that are separated from a contract and paid under a different arrangement.

Case Management
Definition: A method by which a health plan attempts to control costs by directing all of the procedures for care of an individual through a nurse or other health care professional.

Claim
Definition: A request for payment by a medical provider for a given medical service or item.

COBRA
Definition: Consolidated Omnibus Budget Reconciliation Act

Co-insurance
Definition: A percentage the patient is responsible for on a given insurance claim

Contracted Provider
Definition: A medical provider that has an agreement with a health plan to accept their patients at a previously agreed upon rate for payment.

Conversion Plan
Definition: When an individual terminates his/her group policy, an option to continue coverage is by purchasing an individual health plan called a conversion policy.

Co-payment
Definition: A per occurrence payment

Cost Containment
Definition: When the insurance company devises a way to reduce the benefit payment or costs associated with the health plan.

Covered Expense
Definition: A medical procedure or item that is deemed payable by the insurance plan.

CPT Code
Definition: Current Procedural Terminology

Deductible
Definition: A set dollar amount which must be satisfied within a specific time frame before the health plan begins making payments on claims

Exclusions
Definition: Those items or medical services that are not covered by the health plan.

Exclusive Provider Organization (EPO)
Definition: A health plan that has the characteristics of an HMO or PPO plan.

Explanation of Benefits
Definition: A summary of the payment made by your health plan to the medical provider.

Extension of Benefits
Definition: The health plans offers an additional 12 months of coverage due to a disabling condition

Fee for Service
Definition: A method of payment for medical services rendered

Fee Schedule
Definition: A list of CPT codes and dollar amounts an insurance company will pay for a particular medical service

Formulary
Definition: A listing of pharmaceuticals the health plan pays for.

Fully Insured

Definition: An Employer purchases insurance coverage from a licensed insurance company and the insurance company assumes all of the risk.

HCFA 1500
Definition: The standard claim format used by health plans on which to consider payment to the medical provider.

HMO
Definition: Health Maintenance Organization

CD-9 (International Classification of Diseases 9th Edition)
Definition: A standard format of identifying the illness, injury or diseases by using a three digit code.

Indemnity Plan
Definition: A non PPO or HMO plan, a plan that does not have preferred provider networks or many cost containment features.

Integrated Delivery System
Definition: An organization that combines hospital, physician and other medical services as part of a larger health care system.

IPA (Independent Practice Association)
Definition: An organization of physicians who are contracted with an HMO plan.

Managed Care
Definition: A method by which cost containment features are applied to a health plan either by limiting the reimbursement levels paid to providers or by reducing utilization.

Medical Loss Ratio
Definition: The amount of the premium revenues actually spent on paying for medical services.

Medical Necessity
Definition: A medical procedure or service must be performed only for the treatment of an accident, injury or illness and is not considered experimental, investigational or cosmetic.

Off-label Use
Definition: The prescribing of a medication for use not approved by the FDA (Federal Drug Administration).

Out of Pocket Expense
Definition: The amount the patient must pay themselves and not paid for by the insurance plan

Participating Provider
Definition: A physician or other medical provider has agreed to accept a set fee for services provided to members of a specific health plan. They are deemed to be "in-network".

PCP
Definition: Primary Care Physician

PPO

Definition: Preferred Provider Organization

Pre-Existing
Definition: A medical condition diagnosed prior to the effective date of the health plan.

Self-Insured
Definition: An Employer who underwrites their own risk. This may is good for groups with a favorable claims history.

Usual & Customary
Definition: A reduction in the payment of benefits on a claim which is justified by the insurance company as "the going rate" to be paid in that geographical area.

Untimely Submission
Definition: A medical claim must be submitted within the time frame given by the insurance company or the claim will be denied.