Key Insurance and Billing Terminology

Below is a list of common insurance and billing terms to know. The details associated with these terms are unique to you and your health insurance. Please contact your health insurance carrier for specific questions related to your coverage. Additional commonly used insurance terms can be found on the Health Insurance Marketplace website.

  • Insurance Carrier/Provider: The company or organization providing your health insurance coverage, as listed on your health insurance card; insurance carriers provide access to a network of health care services through individual insurance plans/policies.
  • Network: Facilities, care providers, and/or supplies contracted by your insurance carrier to provide health care services. Your insurance carrier may offer “in-network” rates at a discount compared to “out-of-network,” which are typically higher rates.
  • Insurance Plan/Policy: The product you “purchase” from insurance carriers to receive health insurance coverage; plans are paid for by premiums and different plans may have varying levels of coverage.
  • Plan Subscriber: The primary holder of an insurance plan; this individual is responsible for paying premiums and/or maintaining eligibility through their employer and can enroll dependents as plan members.
  • Plan Member: An individual enrolled in an insurance plan; this includes the plan subscriber and any dependents they enroll.
  • Plan Year: A 12-month period where you are covered by your insurance plan; this typically starts and ends with the calendar year.
  • Premium: The amount subscribers pay per month to have health insurance; this is similar to rent for health insurance and typically DOES NOT count towards the deductible or maximum out-of-pocket.
  • Out-of-Pocket: The cost of health care services to you; this typically includes copays, deductibles, and coinsurance.
  • Copay: A pre-set dollar amount you pay for certain covered health care services and supplies at the time of service. Copays typically DO NOT go towards your deductible, but DO go towards your maximum out-of-pocket.
  • Deductible: The amount you must pay for health care services in a plan year before insurance starts paying; this typically resets each plan year and may be separate for each member. Copays and premiums DO NOT typically count towards your deductible.
  • Coinsurance: The amount you pay after the deductible is met; this is usually a percentage of the total bill and the insurance carrier pays the remaining portion. Coinsurance typically counts towards your maximum out-of-pocket.
  • Maximum Out-of-Pocket: The maximum cost you will be required to pay before insurance covers the rest; this typically resets each plan year and may be separate for each member. Copays, coinsurance, and deductibles typically count towards your maximum out-of-pocket, but premiums DO NOT.
  • Covered Service: Services, drugs, supplies, and equipment covered by the terms and conditions of your insurance plan. Certain services may be considered “non-covered” if they are not considered to be medically reasonable to your condition/diagnosis, or if your insurance plan does not include benefits to cover them.
  • Pre-Authorization/Certification: Proof provided to your insurance carrier that the health care service, treatment plan, prescription drug, or equipment is medically necessary; this is NOT a promise your health insurance will cover the cost. UNC Health will help you obtain the necessary approvals for your visit.
  • Explanation of Benefits (EOB): A letter outlining what your insurance carrier is paying on your behalf; this is NOT a bill.
  • Bill: A statement from a health care organization, such as UNC Health, requesting payment for fees related to the service(s) you received; bills comprise facility fees and/or professional fees, which may be listed on one or more statements.
  • Facility Fees: Fees associated with services and supplies provided by the hospital or hospital-based clinic where you receive care; this may include fees associated with your room, supplies used during your visit, and/or support staff (ex. nurses, technicians).
  • Hospital-Based Clinics: Locations that are associated with a hospital and include hospital fees when billing for services; hospital-based clinics may or may not be located on a hospital campus.
  • Professional Fees: Fees associated with services rendered by your care provider(s); you may receive separate bills for one or more care providers based on the type of service you receive (ex. primary care providers, surgeons, anesthesiologist) and your chosen location.
  • Care Providers: Licensed medical professionals responsible for providing the health care services you receive; this includes doctors/physicians, physician assistants, nurse practitioners, therapists, and pharmacists.