Health insurance can sometimes feel complicated, especially when you’re trying to understand what’s covered, whether you need a referral or if your insurance company must approve a service before you receive care.
Here are a few common health insurance terms to know:
Premium: What you pay to maintain your insurance coverage.
Deductible: What you may need to pay for covered services before your insurance begins paying its share.
Copayment: A fixed amount you pay for a covered service.
Coinsurance: The percentage of a covered service’s cost you pay, depending on your plan.
Out-of-pocket maximum: The limit on what you pay for covered services during your plan year, subject to your plan’s rules.
Your costs and coverage depend on your specific insurance plan.
What Are Referrals and Prior Authorizations?
A referral is a request from one health care provider for you to see another provider, often a specialist. Some insurance plans require a referral before covering specialty care.
Prior authorization is when your insurance company reviews a proposed service, procedure or treatment before it is provided. Some plans require this approval for certain tests, procedures or medications.
A referral and prior authorization are different, and your plan may require one, both or neither.
Before scheduling care, contact your insurance company to confirm your benefits, verify that your provider and facility are in-network, and ask whether a referral or prior authorization is required.
Preparing for Your Next Appointment
A few simple steps can help you feel more prepared:
Bring your current insurance information.
Verify your benefits and potential out-of-pocket costs.
Confirm whether referrals or authorizations are needed.
Ask for a cost estimate for planned procedures when available.
If you have questions about billing or financial responsibility, Peterson Health’s Patient Financial Services team can help.
Call 830-258-7423, Monday through Friday, 8 a.m. to 4:30 p.m., or visit Peterson Health Patient Financial Services.
Find Care With Confidence
Understanding your insurance is an important part of navigating health care. Taking time to ask questions and verify your coverage can help you make informed decisions about your care.
Explore Peterson Health’s services and specialties to learn more about care available in the Texas Hill Country.
This article is for general educational purposes. Coverage and requirements vary by insurance plan. Contact your insurance company to confirm your specific benefits.
Need help navigating your health insurance? Visit PetersonHealth.com to explore our services and find care close to home. If you have questions about your coverage, contact your health insurance provider for assistance.
