Term Definitions
Many people are unfamiliar with terms used in their benefits packages. The list below provides definitions for some commonly used terms.
What is an "allowed amount "?
An allowed amount is the charge that BCBSNC determines is reasonable for covered services provided to a member. This may be established in accordance with an agreement between the provider and BCBSNC. In the case of providers that have not entered into an agreement with BCBSNC, the allowed amount will be the lesser of the provider's actual charge or a reasonable charge established by BCBSNC using a methodology that is applied to comparable providers for similar services under a similar health benefit plan. BCBSNC's methodology is based on several factors including the medical, payment and administrative guidelines. Under the guidelines, some procedures charged separately by the provider may be combined into one procedure for reimbursement purposes.
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What is "coinsurance"?
Coinsurance is the amount the member must share in contributing towards the cost of covered medical expenses, usually stated as a percentage of the allowed amount. This is in addition to any copayments, deductibles, and services not covered by the Plan.
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What is a "copayment"?
A copayment or "copay" is the specified portion of a charge for which the member is responsible, such as a prescription drug, office visit, or professional services co-payment.
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What is a "deductible"?
The deductible is the amount of allowable charges that members must pay each Plan year before benefits are payable. The deductible does not include copayments, coinsurance, charges in excess of the allowed amount, amounts exceeding any maximum and expenses for non-covered services.
Note: The information contained in these Frequently Asked Questions does not include all the benefits or everything you need to know about the State Health Plan. Please check your Benefit Booklet for further details. For more information click on the appropriate Benefits Book for your health plan: PPO Basic , PPO Standard , PPO Plus . We encourage you to call if you have questions about any of your health plan benefits. For the contact information, consult our Contact Us page.
An allowed amount is the charge that BCBSNC determines is reasonable for covered services provided to a member. This may be established in accordance with an agreement between the provider and BCBSNC. In the case of providers that have not entered into an agreement with BCBSNC, the allowed amount will be the lesser of the provider's actual charge or a reasonable charge established by BCBSNC using a methodology that is applied to comparable providers for similar services under a similar health benefit plan. BCBSNC's methodology is based on several factors including the medical, payment and administrative guidelines. Under the guidelines, some procedures charged separately by the provider may be combined into one procedure for reimbursement purposes.
Back to top
What is "coinsurance"?
Coinsurance is the amount the member must share in contributing towards the cost of covered medical expenses, usually stated as a percentage of the allowed amount. This is in addition to any copayments, deductibles, and services not covered by the Plan.
Back to top
What is a "copayment"?
A copayment or "copay" is the specified portion of a charge for which the member is responsible, such as a prescription drug, office visit, or professional services co-payment.
Back to top
What is a "deductible"?
The deductible is the amount of allowable charges that members must pay each Plan year before benefits are payable. The deductible does not include copayments, coinsurance, charges in excess of the allowed amount, amounts exceeding any maximum and expenses for non-covered services.
Note: The information contained in these Frequently Asked Questions does not include all the benefits or everything you need to know about the State Health Plan. Please check your Benefit Booklet for further details. For more information click on the appropriate Benefits Book for your health plan: PPO Basic , PPO Standard , PPO Plus . We encourage you to call if you have questions about any of your health plan benefits. For the contact information, consult our Contact Us page.
