PEHP is here to help you navigate the challenges and opportunities of health care to avoid unnecessary large medical bills. Below is a list of common medical insurance terms and definitions.
Your deductible is the amount you pay toward your claims before PEHP begins paying for certain benefits. Deductibles can vary from hundreds to thousands of dollars depending on your plan. Track your spending toward your deductible at PEHP for Members.
Your co-pay is a set dollar amount you pay for a service. Some plans require a specific co-payment, such as $25 or $35, for a doctor’s office visit. See your plan's co-payments in your Benefits Summary at PEHP for Members.
A claim is a detailed invoice that your health care provider (such as your doctor, clinic, or hospital) sends to PEHP to collect payment for services you received. This invoice shows exactly what services you received. You can view your claims when you log in to PEHP for Members (click on the "Claims" icon on the top right).
An exclusion is a specific condition, circumstance, or prescription for which PEHP will not cover. Log in to PEHP for Members to see a list of exclusions in your Master Policy (click "Benefit Information Library" under the "my Benefits" menu).
Balance billing happens when an out-of-network provider charges more than the in-network rate.
Balance billing can result in significant, unexpected bills, because PEHP has no pricing agreements with out-of-network providers. Unless you have made previous arrangements, they are under no obligation to bill within a certain amount. Nothing you pay for balance billing counts toward your deductible or out-of-pocket maximum.
How can you avoid balance billing? First, make sure make sure every person and every facility involved in your care is in your medical or dental network. Find in network providers at PEHP for Members (click “Find and Select a Provider” under the "my Benefits" menu).
If you can’t avoid seeing an out-of-network provider, consider negotiating a price beforehand. It can help to know the in-network fee, which you can find
using the cost tools available at PEHP for Members.
Request to have a provider added to your network by filling out this form.