Understanding Insurance Benefits & Terminology

What is a copay?
A copay is a predetermined fixed amount created by your insurance that is considered the customer’s portion of payment for a medical service. This typically needs to be paid at each visit. 

What is a coinsurance?
A Coinsurance is a percentage of a charge that is considered the customer’s portion of payment for a medical service. Individual insurances can have a different co-insurance amounts. 

What is a deductible?
A deductible is a set amount of money that is required for the customer to pay prior to the insurance beginning to make payment for medical services. 

What is an out-of-pocket maximum?
An out-of-pocket maximum is a set amount a customer is responsible for paying for covered services in a year. Once this amount is met, the insurance typically covers 100% of costs for medical services. 

What is a contracted discount with insurance?
A contracted discount is an agreed upon discounted cost for a service between the organization (Oaklawn) and the insurance company as part of the provider network agreement. 

What is an authorization?
An authorization is a form of a pre-approval for medical services. Some insurances require this process before services can be completed, others do not. 

What does In-Network and Out-of-Network mean?
Oaklawn is In-Network and has contracts with most insurance companies. If your insurance company is Out-Of-Network (does not have a contract with Oaklawn), you can still have services at Oaklawn, but your cost may be different. 

To check your benefits, the phone number to your insurance is typically located on the back of your insurance card. 

Understanding Outpatient therapy terminology within Oaklawn:

  • Habilitative versus rehabilitative
    • Habilitative services are therapy services that assist in developing skills or abilities that have not been present or developed by the patient. The need for therapy is not caused by an illness or an injury. It is important to remember that some insurances do not cover habilitative services. 
    • Rehabilitative services are therapy services utilized to assist a patient with regaining or redeveloping functional abilities that were lost due to illness or injury. These types of services are typically covered by insurances. 

Checking your benefits for Oaklawn Rehabilitation (Physical, Occupational, and Speech Therapy):

  • Oaklawn provides therapy services as “Hospital Outpatient” therapy services.
    • This is important to state when verifying your benefits for outpatient therapy with your insurance company. 
  • ICD code
    • ICD 10 codes are the medical codes used to identify the diagnosis a patient is being seen for within therapy. Some insurances require this code when verifying benefits. This can be found on your referral to therapy (labeled ICD -10) or staff can assist you with identifying this if needed. 
  • CPT codes
    • CPT Codes are used to describe the therapy procedures that may be performed by your therapist. Some insurance companies require these to verify your benefits. Staff can provide these codes to you if needed. 

*Some insurances require Oaklawn’s NPI number for determining in-network versus out-of-network. 

Oaklawn Hospital NPI #186 147 5360

*Some insurances require your therapy referral to be signed by a Medical Doctor (M.D.) or Doctor of Osteopathic Medicine (D.O.) and will not accept a referral from an advanced practice provider such as a Nurse Practitioner (N.P.) or Physician’s Assistant (P.A.). 

We contact your insurance provider as a courtesy to you prior to your first visit, however it is important to understand your own coverage and benefits. We encourage you to contact your insurance prior to services being rendered.