Health Insurance Member Services Knowledge

01Deductible & Out-of-Pocket Maximum

The deductible is what a member pays for covered services before the plan starts paying (except certain free preventive care). The out-of-pocket maximum is the most a member pays in a plan year; after reaching it, the plan covers 100% of in-network covered benefits for the rest of the year.

02Copay vs. Coinsurance

A copay is a fixed dollar amount per service (e.g., $30 per visit). Coinsurance is a percentage of the cost paid after the deductible is met (e.g., 20% of a $500 service = $100). They are not interchangeable terms.

03Explanation of Benefits (EOB)

An EOB shows how a claim was processed and what the plan paid versus what the member may owe. It is explicitly not a bill — any amount actually due comes as a separate bill from the provider.

04Prior Authorization vs. Referral

A referral is a provider-to-provider recommendation directing a patient to a specialist or other service. Prior authorization is the health plan's approval that a specific service or medication is medically necessary and covered before it happens.

05In-Network vs. Out-of-Network

In-network providers have negotiated/contracted rates with the plan, generally resulting in lower member costs. Out-of-network providers do not, which usually means higher costs or reduced/no coverage depending on the plan type.

06HIPAA Verification, Appeals & Grievances

Agents must verify a caller's identity and authorization before discussing any protected health information, regardless of claimed relationship (e.g., spouse). An appeal requests reconsideration of a specific coverage/claim decision, while a grievance is a complaint about service or plan operations that isn't tied to reversing a coverage decision.