The healthcare professional has a contract with your insurance company agreeing to a dollar amount for a service and adjusts the fee based on the contract amount.

The healthcare professional does not have a contract for services with the insurance company. There may be benefits available; however, the benefit is not determined until the claim is reviewed. Therefore, the insurance company is not able to provide the dollar amount for a service to an out-of-network provider.

With an HMO you have benefits available only when you receive services from an in-network or contracted provider. PPO plans allow benefits for both in and out-of-network providers. Occasionally, if receiving a service from an out-of-network provider or facility, the benefit may be reduced, but there is still some dollar amount. 

The dollar amount that must be satisfied prior to the insurance plan making any payment reimbursement.

The percentage the member is responsible for covering after the deductible is met. 

The arbitrary amount an insurance company sets as the fee for a particular product, procedure, or service.  For example we will bill the insurance the full fee for each service, but your benefit coverage or payment will be based on the dollar amount they have chosen. 

There are times where an insurance plan or group will not provide any payment or allow any benefit for a particular diagnosis or service. Limitations are occasionally seen as the maximum amount an insurance company will allow or pay for a particular diagnosis or service. The limit can be either in the form of a dollar amount or a percentage.