Insurance Terminology Definitions

Insured patients:  For patients with health insurance coverage, we will submit a claim on behalf of the patient to insurance companies with whom we are contracted (where we are considered a participating provider). Prior to your visit, we will also verify your member eligibility and covered benefits by contacting your insurance company.

Referrals:  Some insurance plans require the patient to have a referral (an authorization number generated from the insurance carrier, whereby the insurance carrier will need to be contacted) from your primary care physician to see a specialist, such as a urologist.  Patients are required to obtain referrals from the primary care physician office prior to scheduling an appointment with our providers.  If a referral is not obtained prior to the appointment, the insurance carrier will not cover the cost of the visit.  Please check with your individual insurance plan to see if a referral is necessary.

Copayments:  Copayments, or copays, are the fixed amount a patient pays for a healthcare service as determined by the patient’s individual health insurance plan.

Coinsurance:  Coinsurance is your share (not a fixed dollar amount, but a fixed percentage) of the cost of the service. Patients pay a fixed percentage of medical expenses after the deductible amount is met.

Deductibles:  A deductible is a dollar amount set by the individual’s insurance plan at the time the plan becomes activated.  Patients must pay out of pocket towards meeting that dollar amount before the insurance company will start to pay for covered services. Plans usually have both individual and family deductibles, whereby both have to be met for insurance to pay for covered services at 100 percent.  Before insurance will pay at 100 percent, the patient will pay a set percentage called a coinsurance.

Outstanding Balances:  An outstanding balance with AUNC is the final amount due, that has not been covered by the insurance plan.   It is the patient’s responsibility to pay this amount.  There may still be an outstanding balance after the patient has paid, as well as after the insurance plan has paid.

Patient Refunds:  If after you have paid your estimated patient responsibility (co-pay or coinsurance), and after the insurance payment has been received by the practice, we will process your refund.  Refunds are issued on and we will mail you a check via the United States Postal Service (USPS).

Self-Pay Patients:  Patients who do not have insurance coverage or who desire services that are not covered by their insurance plan are considered self-pay. If you are self-pay, all payments must be made in full at the time of service unless other arrangements have been made per the rendering physician’s approval.   Our patient billing team is available to assist with payments.  And our financial counselor will be able to assist with payment assistance and options.

Non-Covered Services:  These are services that are NOT covered by a patient’s insurance plan.  Per AUNC’s Financial Policy (click here for full printable document), all monies owed shall be paid before the time of service and will be calculated at the self-pay rate.

Pre-authorization:  Most insurance plans require a pre-authorization approval for certain procedures and / or surgeries.  Once a treatment plan has been determined by the urologist and the patient, the pre-authorization process may begin.  The surgery or procedure will be scheduled after our office has received an approved pre-authorization.  Please understand that approval of a pre-authorization for a surgery or procedure does NOT guarantee that the health insurer will pay for the service.

Diagnostic Testing (Lab Services):  Your urologist may request blood tests, tissue samples and other specimens to assist in the proper diagnosis and management of your urologic condition.  While some lab work is performed at AUNC’s in-house pathology lab, you may be required to visit a third-party or outside lab such as Quest or LabCorp.   Please know that you will receive a separate bill from the third-party lab for specimens that are NOT processed through AUNC’s in-house pathology lab.