Understanding Insurance
Under your health plan, you are responsible for certain cost-sharing amounts, including copayments, coinsurance and deductibles. You may have additional costs or be responsible for the entire bill if Confluence Health is not within your insurance plan’s network. This is often referred to as “surprise billing” or “balance billing.” However, in many scenarios you are protected by law from receiving a balance bill for your care. For details on your rights as a patient with regards to balance billing, please click this notice.
Many health insurance plans have pre-certification or prior authorization requirements for specific services and procedures. In some instances, referrals are required. Information about referrals is typically listed on the back of your healthcare insurance card. Please refer to your card, your benefits handbook, or contact your health insurance’s customer service department for more information on referral requirements.
Some important items to remember when obtaining an authorization or referral include:
- Allowed Amount: The amount the insurance company pays for a service (may be less than what we have billed).
- Authorization / Pre-Authorization: Formal approval by insurance to assist patient and provider in securing payment for healthcare services.
- Benefit Period: When services are covered under your plan. It also defines the time when benefit maximums, deductibles and coinsurance limits build up. It has a start and end date. It is often one calendar year for health insurance plans.
Example: You may have a plan with a benefit period of January 1 through December 31 that covers 10 physical therapy visits. The 11th or more session will not be covered. - Charge: Price for services rendered.
- Coinsurance: A certain percent you must pay each benefit period after you have paid your deductible. This payment is for covered services only. You may still have to pay a copay. Example: Your plan might cover 80 percent of your medical bill. You will have to pay the other 20 percent. The 20 percent is the coinsurance.
- Contractual Allowance / Adjustment: The difference between what an insurance company approves according to its contract and what the healthcare provider charges for the service.
- Copayment (Copay): The amount you pay to a healthcare provider at the time you receive services. You may have to pay a copay for each covered visit to your doctor, depending on your plan. Not all plans have a copay. (i.e. $20 for every visit to the doctor, while your insurance pays the rest).
- Cost: Patient’s out-of-pocket responsibility for services rendered.
- Covered Person: Any person covered under the plan.
- Covered Service: A healthcare provider’s service or medical supplies covered by your health plan. Benefits will be given for these services based on your plan.
- CPT Code: Five-digit code(s) used to describe tests, surgeries, evaluations, and any other medical procedure performed by a healthcare provider on a patient.
- Deductible: The amount you pay for your healthcare services before your health insurer pays. Deductibles are based on your benefit period (typically a year at a time). Example: If your plan has a $2,000 annual deductible, you will be expected to pay the first $2,000 toward your healthcare services. After you reach $2,000, your health insurer will cover the rest of the costs.
- Dependent Coverage: Coverage for your dependents who qualify.
- Explanation of Benefits (EOB) or Explanation of Payment (EOP): These are documents showing a detailed listing of how your insurance company processed your claim or bill. An EOB or EOP is mailed by your insurance company directly to you.
- Established Patient: For billing purposes, an established patient is defined as someone who has been seen by the provider/department within the last three years.
- HCPCS: Is a collection of standardized codes that represent medical procedures, supplies, products and services.
- HMO – Health Maintenance Organization: An HMO requires the member to choose a provider network and a primary care provider (PCP) within the chosen network. An approved referral from his/her PCP must be in place for a member to see a specialist. If a referral is not in place prior to receiving non-emergent care, the HMO may not cover incurred services.
- Inpatient Services: Services received when admitted to a hospital and a room and board charge is made.
- Insurance: Coverage that pays for medical and surgical expenses incurred by the insured and/or eligible dependents.
- Medicare A: Medicare Part A provides payments for inpatient hospital services, excluding those of physicians and surgeons.
- Medicare B: Part B provides payments to physicians and surgeons, as well as for medically necessary outpatient hospital services (such as ER, laboratory, X-rays and diagnostic tests) and certain durable medical equipment and supplies.
- Medicare Advantage Plan: Medicare Advantage plans are private health plans that have contracted with Medicare. These plans are paid fixed subsidies by Medicare to provide Medicare beneficiaries benefits. Most of these plans are managed care plans, which are plans that control both the financial and health services portion of the insurance plan.
- New Patient: For billing purposes, a new patient is defined as someone who has not been seen by the provider/department within the last three years.
- Non-covered Charges: Charges for services and supplies that are not covered under the health plan. Examples of non-covered charges may include things like acupuncture, weight loss surgery or marriage counseling. Consult your plan for more information.
- Observation: Is a special service or status that allows physicians to place a patient in an acute care setting, within the hospital, for a limited amount of time (generally 24 to 48 hours) to determine the need for inpatient admission.
- Outpatient Services: Services that do not need an overnight stay in a hospital. These services are often provided in a doctor’s office, hospital or clinic.
- OON – Out of Network: Health care rendered to a patient outside of the health insurance company’s network of preferred providers. In many cases, the health insurance company will not pay for these services. Emergency medical care is usually an exception to the OON rule.
- Out-of-Pocket Maximum: The most money you will pay during your coverage period, includes deductibles, co-payments, co-insurance and balance-billed charges, but is in addition to your regular premiums.
- POS – Point of Service Program: A POS has the same requirements as an HMO. However, members are given the additional option of self-referring outside of their PCP network. Members who choose to self-refer will incur a higher out of pocket cost.
- PPO – Preferred Provider Organization: A PPO offers a network of providers. Members have the choice to access several providers but are given financial incentives (i.e., lower out-of-pocket costs) to use the preferred provider network.
- Premium: Payments you make to your insurance provider to keep your coverage. The payments are due at certain times.
- Price: Price of premiums, price of services.
- Primary Care: General internal medicine, family practice and pediatrics providers.
- Prior Authorization: A request for payment authorization submitted in advance by a healthcare provider to the insurance plan for their approval to admit a patient, perform a procedure or provide a service. Pre-authorization / prior-authorization requirements are specific to each insurance plan. The insurance plan will determine medical necessity, appropriateness of services and level of care based upon their own guidelines.
- Referral: An insurance pre-approval required from the patient’s PCP BEFORE seeing a specialist.
- Self-refer: An insurance member’s ability to receive specialty care services without written referral from member’s primary care provider and approval from their insurance. These services, however, may be denied or paid at a lesser benefit.
- Qualifying Life Event (to Change Insurance): A change in your life that can make you eligible for a special enrollment period to enroll in health coverage. Examples of qualifying life events are moving to a new state, certain changes in your income, and changes in your family size (for example, if you marry, divorce, or have a baby) and gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder.
In-Network Plans & Payers
Confluence Health is contracted with the following insurance payers and plans. Insurance plan coverage can change at any time. Please review your network status, insurance plan benefits, copays, annual deductible and coinsurance to be informed about your coverage. If you have any questions, please contact your plan to confirm that your care at Confluence Health will be covered prior to receiving services. Your benefit plan may utilize a network that Confluence Health does not participate with.
Note: Centene will be changing coverage for 2027:
- Centene will no longer offer its Medicare Advantage product (Wellcare) in the state of Washington but will continue to offer its DSNP products for those Medicare eligible individuals who qualify. For Wellcare members who need assistance, please contact Washington Senior Support at waseniors.org for free independent guidance on Medicare Advantage changes and other coverage options in Washington.
- Centene will no longer offer its insurance exchange product (Ambetter) in the individual markets in Chelan, Douglas and Okanogan counties. However, Ambetter will continue to be offered in most other counties in the state including Grant County. For assistance with coverage in an individual market, please visit wahealthplanfinder.org.
In-Network Plans/Payers Accepted at Confluence Health
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