Allowance: What a plan will pay for covered out-of-network services before cost-sharing is applied.
Cost-Sharing: The portion of the plan’s schedule or allowance that plan members pay to use covered health services. There are three possible types of cost-sharing: copay, coinsurance and deductible. The amount of these costs depends on your specific health plan. For out-of-network benefits, cost-sharing does not include the difference between Carelon Behavioral Health’s allowance and the provider’s charges, which you are also responsible to pay (in addition to cost-sharing).
Explanation of Benefits (EOB): A summary of our payment decision(s) relating to a claim for health care services.
In-Network Provider: A physician or other health care provider, or a health care facility, that participates in your health plan’s provider network.
Network: Group of physicians, hospitals and other health care providers with whom a health insurer contracts to deliver medical services to its plan members.
Out-of-Network Provider: A physician or other health care provider, or a health care facility, who does not participate in your health plan’s provider network.