Every confusing term on your medical bill, explained in plain English. From "allowable charge" to "utilization review" — we've got you covered.
The maximum amount your insurance company will pay for a specific medical service or procedure. If your provider charges more than the allowable amount, you may be responsible for the difference. This is also called the "allowed amount" or "eligible expense." Review your bill to see if you were charged above the allowable amount.
A formal request to your insurance company to reconsider a claim they denied or only partially paid. You have the right to appeal most coverage decisions, and there are usually multiple levels of appeal available — internal and external. Deadlines vary by plan, so act quickly after receiving a denial.
An agreement that allows your healthcare provider to receive insurance payments directly from your insurance company on your behalf. Without this, the insurance check goes to you and you'd need to pay the provider yourself. Most providers require you to sign this when you check in.
Approval from your insurance plan before you receive certain medical services, ensuring the service is covered. Also known as prior authorization or precertification. Without authorization, your insurer may refuse to pay the claim, leaving you with the full bill.
Money owed to a healthcare provider for services already delivered. When you see a balance on your patient portal or receive a statement, that's the provider's A/R from you. Unpaid A/R can eventually be sent to collections.
The process your insurance company uses to review and decide how much to pay on a submitted claim. During adjudication, the insurer checks your coverage, verifies the charges, and determines your share. The result appears on your EOB.
Medical services provided on an outpatient basis — meaning you don't stay overnight. This includes doctor visits, same-day surgery, diagnostic tests, and rehab. Ambulatory care is typically less expensive than inpatient hospital stays.
When a healthcare provider bills you for the difference between their charge and what your insurance paid. This commonly happens with out-of-network providers. The No Surprises Act now protects you from balance billing in many emergency and certain non-emergency situations.
The time frame during which your health plan benefits are available — usually a calendar year (January to December). Your deductible and out-of-pocket maximum reset at the start of each new benefit period.
A set of standards guaranteeing patients certain rights in healthcare settings, including the right to receive an itemized bill, understand charges, and dispute errors. Many states have their own patient bill of rights with specific billing protections. Learn about your rights.
A single payment that covers all services related to a specific treatment or condition, rather than billing each service separately. For example, a hip replacement bundle might include the surgery, hospital stay, anesthesia, and follow-up visits in one price. This approach can save you money by encouraging efficiency.
A request submitted to your insurance company for payment of a medical service. Your provider files claims on your behalf using procedure codes (CPT) and diagnosis codes. If a claim is denied, you can file an appeal.
The Consolidated Omnibus Budget Reconciliation Act — a federal law that lets you temporarily continue your employer-sponsored health insurance after losing your job or experiencing certain qualifying events. COBRA coverage can be expensive because you pay the full premium (employer and employee portions) plus an admin fee.
The percentage of a medical bill you pay after meeting your deductible. For example, if your plan has 20% coinsurance, you pay 20% and your insurance pays 80%. Coinsurance continues until you reach your out-of-pocket maximum.
A fixed dollar amount you pay for a covered healthcare service at the time you receive it. For example, you might pay $30 for a doctor visit or $15 for a prescription. Copays don't usually count toward your deductible but often count toward your out-of-pocket maximum.
The portion of healthcare costs you pay out of your own pocket, including deductibles, copays, and coinsurance. Understanding your cost-sharing structure is key to predicting what you'll owe. Upload your bill and we'll break down your cost sharing.
Current Procedural Terminology — a standardized set of 5-digit codes used to describe medical procedures and services on your bill. Every test, visit, and procedure has a specific CPT code. If your bill looks wrong, checking the CPT codes can help you identify unbundling or incorrect charges.
The process by which insurance companies verify a healthcare provider's qualifications, licensure, and background before allowing them to join a network. If your provider hasn't completed credentialing with your insurer, they may be considered out-of-network even if they said they accept your insurance.
The process that determines which insurance plan pays first when you're covered by two or more health plans. The primary plan pays first, then the secondary plan may cover some or all of the remaining balance. Proper COB can significantly reduce your out-of-pocket costs.
Medical services, procedures, and treatments that your health insurance plan will help pay for. Each plan defines its own covered services in the plan documents. Services not on the list are considered exclusions and you'll pay the full cost yourself.
The amount you pay out of your own pocket for covered healthcare services before your insurance starts paying. For example, with a $1,500 deductible, you pay the first $1,500 of covered services yourself. After that, you typically share costs through coinsurance. Your deductible resets each benefit period.
When your insurance company refuses to pay for a medical service or procedure. Common reasons include missing prior authorization, services deemed not medically necessary, or billing errors. You always have the right to appeal a denial.
A classification system that groups hospital inpatient stays into categories based on diagnosis, procedures, age, and complications. Hospitals receive a fixed payment per DRG from Medicare and many insurers, regardless of the actual cost of treatment. This is why the same procedure can cost very differently at different hospitals.
Medical equipment prescribed by a doctor for use at home, such as wheelchairs, CPAP machines, walkers, or oxygen equipment. Insurance typically covers DME but may require prior authorization and may only cover rental rather than purchase. Compare DME costs near you.
The specific date when you received a medical service or treatment. This date appears on your bill and EOB and is important for verifying charges, filing claims, and meeting timely filing deadlines. Always check the date of service against your own records.
A statement from your health insurance company that explains what medical services were billed, how much was covered, and what you may still owe. An EOB is not a bill — it's a summary to help you understand how your claim was processed. Always compare your EOB to the actual bill you receive. Upload your bill and EOB for a side-by-side analysis.
A medical condition with severe symptoms (including severe pain) that a reasonable person would believe requires immediate attention to prevent serious harm. Under federal law, emergency rooms must treat you regardless of insurance or ability to pay. The No Surprises Act protects you from surprise bills for emergency care.
A set of 10 categories of services that all ACA-compliant health plans must cover, including hospitalization, prescription drugs, maternity care, mental health, and preventive care. Plans can vary in how much they charge for these services, but they must offer coverage in all 10 categories.
A specific condition, treatment, or service that your health insurance plan does not cover. Exclusions vary by plan and are listed in your plan documents. Common exclusions include cosmetic surgery, experimental treatments, and certain alternative therapies. If a service is excluded, you pay 100% out of pocket.
All the medical services related to treating a specific condition from start to finish. For example, a knee replacement episode might include pre-op testing, the surgery itself, hospital stay, and physical therapy. Some insurers and providers use episode-based pricing for bundled payments.
A charge from a hospital or medical facility for the use of their building, equipment, and staff — separate from the doctor's professional fee. This is why a simple blood draw at a hospital might cost 3x more than at a standalone lab. Compare facility fees for your procedure.
Programs offered by hospitals and medical facilities that reduce or eliminate medical bills for patients who can't afford to pay. Nonprofit hospitals are required to have financial assistance policies. You typically need to apply and provide income documentation. Learn how to apply for financial assistance.
A list of prescription drugs covered by your health insurance plan, organized into tiers that determine your cost. Tier 1 drugs (usually generics) have the lowest copay, while specialty drugs on higher tiers cost more. If your medication isn't on the formulary, you may pay full price or need to request an exception.
A complete listing of fees that a healthcare provider or insurance plan uses to pay for medical services. Medicare publishes its fee schedule publicly, and private insurers negotiate their own rates with providers. Understanding fee schedules helps you know what to expect on a bill.
A set amount of time after your premium due date during which you can still make a payment without losing your health coverage. For ACA marketplace plans, the grace period is typically 90 days if you received a subsidy, or 30 days otherwise. Don't miss it — losing coverage can mean waiting for the next enrollment period.
A formal complaint you file with your insurance company about anything other than a claim denial — such as quality of care, wait times, customer service issues, or network adequacy. Unlike an appeal, a grievance addresses how you were treated rather than whether a specific claim should be paid.
Health insurance coverage offered by an employer or organization to its employees or members. Group plans typically have lower premiums than individual plans because the risk is spread across many people. Your employer usually pays a portion of the premium on your behalf.
A requirement that insurance companies must sell you a policy regardless of your health status, age, gender, or pre-existing conditions. Under the ACA, all marketplace health plans are guaranteed issue during open enrollment and special enrollment periods.
A written estimate of expected charges for a scheduled medical service that healthcare providers must give uninsured or self-pay patients. Required under the No Surprises Act, the estimate must be provided before your appointment. If the final bill is $400+ more than the estimate, you can dispute it.
A standardized coding system used to identify medical services, procedures, and equipment for billing purposes. HCPCS includes CPT codes (Level I) and additional codes for things like ambulance services, DME, and prosthetics (Level II). These codes appear on your detailed bill.
A tax-advantaged savings account available to people enrolled in a high-deductible health plan (HDHP). You can contribute pre-tax dollars and use them to pay for qualified medical expenses, including deductibles, copays, and prescriptions. Unused funds roll over year to year — it's basically a retirement account for healthcare.
The Health Insurance Portability and Accountability Act — a federal law that protects the privacy and security of your health information. HIPAA gives you the right to access your medical records and controls how providers and insurers share your data. It also sets standards for electronic healthcare transactions, including billing.
A type of health insurance plan that requires you to choose a primary care physician (PCP) and get referrals to see specialists. HMOs typically only cover care from in-network providers (except emergencies). They usually have lower premiums but less flexibility than PPO plans.
A supplemental insurance policy that pays you a fixed cash amount for each day you're hospitalized, regardless of other coverage. The money is paid directly to you and can be used for anything — medical bills, rent, childcare, or lost wages. It doesn't replace health insurance but helps cover gaps.
A health plan with a higher-than-average deductible but lower monthly premiums. For 2026, a plan qualifies as an HDHP if the deductible is at least $1,650 for individuals or $3,300 for families. HDHPs are the only plans that let you open an HSA.
Healthcare providers, hospitals, or facilities that have a contract with your health insurance plan to provide services at negotiated, lower rates. Using in-network providers almost always saves you money. Search in-network providers and compare costs near you.
An external review by independent medical professionals when you disagree with your insurance company's denial of a claim. After exhausting internal appeals, you can request an IMR. The reviewers aren't employed by your insurer, and their decision is usually binding on the insurance company.
A patient who is formally admitted to a hospital and stays overnight or longer for treatment. Inpatient care is generally more expensive than outpatient or ambulatory care. Your classification as inpatient vs. outpatient (observation status) significantly affects what you pay.
The state official who regulates the insurance industry in your state, including health insurance companies. If you have a complaint about your insurer — such as unfair claim denials or balance billing — you can file a complaint with your state's insurance commissioner.
A detailed breakdown of every charge on your medical bill, listing each service, supply, and medication with its individual cost and billing code. You always have the right to request an itemized bill. It's the best tool for spotting errors and overcharges. Upload your itemized bill for a free review.
An independent nonprofit that accredits and certifies healthcare organizations and programs in the United States. Joint Commission accreditation is considered a gold standard of quality. If a hospital is Joint Commission-accredited, it has met rigorous safety and care standards.
In health insurance context, a key person typically refers to the primary policyholder or the individual whose employment provides group health plan coverage for dependents. Understanding who the key person is matters when coordinating benefits or navigating COBRA eligibility.
A cap on the total amount an insurance company will pay for covered benefits over your lifetime. The ACA eliminated lifetime maximums for essential health benefits, but some non-ACA plans (like short-term health insurance) may still have them. Check your plan details carefully.
The percentage of premium dollars an insurance company spends on actual medical care and quality improvement versus administrative costs and profit. The ACA requires insurers to spend at least 80% (individual/small group) or 85% (large group) on medical care. If they don't, you get a rebate.
The intensity of medical treatment or supervision required for a patient. Levels range from basic outpatient visits to intensive inpatient care. Your insurer may review the level of care to ensure it's appropriate — for example, questioning whether a hospital admission was truly necessary versus outpatient treatment.
A joint federal-state program that provides free or low-cost health coverage to people with limited income, families, children, pregnant women, seniors, and people with disabilities. Eligibility and benefits vary by state. If you qualify, Medicaid can cover most or all of your medical expenses.
A federal health insurance program primarily for people 65 and older, as well as some younger people with disabilities. Medicare has several parts: Part A (hospital), Part B (medical), Part C (Medicare Advantage), and Part D (prescriptions). Understanding which parts you have affects what you pay on medical bills.
A standard used by insurance companies to determine whether a treatment, service, or supply is needed to diagnose or treat your condition. If your insurer decides something isn't "medically necessary," they may deny the claim. This is one of the most common reasons for claim denials — and one of the most successfully appealed.
A digital file containing negotiated rates between health insurers and providers, published as required by the Transparency in Coverage rule. MRFs are how Taven and similar tools access the actual prices insurers pay for services. These files make it possible to compare real healthcare costs.
A two-digit code added to a CPT code that provides extra information about the service performed. For example, modifier -25 indicates a significant, separately identifiable evaluation on the same day as a procedure. Modifiers can change how much your insurer pays — or if they pay at all.
The group of doctors, hospitals, pharmacies, and other healthcare providers that your insurance company has contracted with to provide services at reduced rates. Staying in-network saves you money. Search your network to find providers and compare costs.
A federal law (effective January 2022) that protects patients from unexpected medical bills for emergency services, air ambulance services from out-of-network providers, and certain non-emergency services at in-network facilities. Under this law, you can only be charged in-network rates in these situations. Learn about your protections.
A healthcare provider who doesn't have a contract with your insurance company — also known as out-of-network. Non-par providers haven't agreed to accept your insurer's negotiated rates, which often means higher costs for you. Always verify your provider's network status before a visit.
A unique 10-digit identification number assigned to every healthcare provider in the U.S. — individual doctors and organizations alike. NPIs appear on claims and billing documents and are used to track providers across the healthcare system. You can look up any provider's NPI in the public NPPES database.
Healthcare providers who don't have a contract with your insurance plan. You'll typically pay significantly more for out-of-network care, and some plans (HMOs) won't cover it at all except in emergencies. The No Surprises Act limits some out-of-network charges.
The most you'll pay for covered healthcare services in a plan year. After you reach this amount, your insurance pays 100% of covered services for the rest of the year. This includes deductibles, copays, and coinsurance — but not your monthly premium.
Medical care where you don't stay overnight in a hospital. This includes doctor visits, same-day surgeries, lab tests, and imaging. Outpatient care is almost always cheaper than inpatient care. Even if you spend many hours at a hospital, you may be classified as outpatient (observation status).
A hospital classification where you're monitored and treated but technically considered outpatient, even if you're in a hospital bed overnight. This classification matters because it affects your insurance coverage — particularly for Medicare patients, who may pay more under observation than under a formal inpatient admission.
A type of health insurance plan that gives you more flexibility in choosing doctors and hospitals. You can see out-of-network providers without a referral, though you'll pay less for in-network care. PPOs typically have higher premiums than HMOs but offer more provider choice.
A health insurance plan that combines features of HMOs and PPOs. Like an HMO, you choose a primary care physician and need referrals for specialists. But like a PPO, you can see out-of-network providers at a higher cost. POS plans offer a middle ground between cost savings and flexibility.
See Prior Authorization. These terms are used interchangeably and both mean the same thing — getting advance approval from your insurer before receiving certain services.
Healthcare services designed to prevent illness or detect conditions early, such as annual checkups, vaccinations, screenings, and wellness visits. Under the ACA, most preventive care must be covered at 100% (no copay or deductible) when you use in-network providers.
Approval from your insurance company that you must get before receiving certain medical services, procedures, or medications. Without prior authorization, your insurance may refuse to pay the claim — leaving you with the full bill. Your doctor's office usually handles the prior authorization process on your behalf.
Any person or organization that provides healthcare services. This includes doctors, nurse practitioners, hospitals, clinics, labs, and pharmacies. On your bill, you may see charges from multiple providers for a single visit — for example, separate bills from the facility and the physician.
The entity that pays for your healthcare services — typically your insurance company, Medicare, or Medicaid. In billing terms, the "payer" is the insurance company, not you. Your share is the patient responsibility after the payer processes the claim.
The portion of a medical bill that you owe after your insurance has processed the claim. This includes your deductible, coinsurance, copays, and any non-covered services. This is the amount you'll see on your actual bill from the provider.
A major life change that triggers a Special Enrollment Period, allowing you to sign up for or change health insurance outside of open enrollment. Examples include getting married, having a baby, losing other coverage, or moving to a new area. You typically have 60 days from the event to enroll.
The average amount charged by providers in your geographic area for a specific service. Insurance companies use R&C rates to determine how much they'll pay for out-of-network claims. If your provider charges more than the R&C amount, you may be responsible for the difference. See also: UCR.
A written order from your primary care physician to see a specialist or get certain medical services. HMO plans typically require referrals, while PPO plans usually don't. Without a required referral, your insurance may not cover the specialist visit.
A document sent from the insurance company to the healthcare provider explaining how a claim was processed and how much was paid. Think of it as the provider's version of your EOB. It includes adjustment codes that explain any differences between what was billed and what was paid.
A four-digit code used on hospital bills (UB-04 claim forms) to categorize the type of service or department — such as room and board, pharmacy, lab, or emergency room. Revenue codes help explain what department provided each service on your itemized bill.
Paying for medical services out of your own pocket without using insurance. Many providers offer significant self-pay discounts (sometimes 40-60% off). If you're uninsured or have a high deductible, ask about self-pay rates — they can sometimes be cheaper than using insurance. Compare self-pay prices.
An unexpected event in a healthcare setting that results in death, permanent harm, or severe temporary harm — such as wrong-site surgery or medication errors. These should never happen. If a sentinel event occurs during your care, you should not be responsible for costs related to the error.
A time outside the annual open enrollment window when you can sign up for health insurance or change plans, triggered by a qualifying life event like losing coverage, moving, getting married, or having a baby. SEPs typically last 60 days from the triggering event.
The process by which your insurance company seeks reimbursement from a third party who caused your injury. For example, if you're in a car accident and the other driver is at fault, your health insurer may pay your medical bills upfront, then pursue the at-fault driver's insurance to recover those costs.
A standardized document that all health insurance plans must provide, summarizing key features like deductibles, copays, out-of-pocket maximums, and covered services in plain language. It's designed to help you compare plans apples-to-apples. Always read the SBC before choosing a plan.
A detailed receipt provided by your healthcare provider that includes diagnosis codes, CPT codes, charges, and provider information. You can use a superbill to submit claims to your insurance company yourself, which is common with out-of-network providers. It contains everything your insurer needs to process the claim.
An unexpected medical bill from an out-of-network provider that you didn't choose — like an anesthesiologist at an in-network hospital. The No Surprises Act now protects you from most surprise bills for emergency and many non-emergency situations. Learn about your rights.
A second health insurance plan that may cover costs your primary insurance doesn't pay, such as remaining coinsurance or deductible amounts. Coordination of benefits rules determine which plan pays first and how the secondary plan covers the rest.
A company that handles administrative tasks for self-funded health plans, including processing claims, managing the provider network, and handling customer service. If your employer self-funds their health plan, the name on your insurance card might be the TPA, not the actual plan sponsor.
The deadline by which a healthcare provider must submit a claim to your insurance company — typically 90 days to one year from the date of service. If a provider misses the timely filing deadline, the insurer can deny the claim, and the provider generally cannot bill you for the amount. If you receive a bill long after treatment, ask about timely filing.
Federal rules requiring hospitals and insurance companies to publicly disclose their prices for medical services. Hospitals must post their standard charges online, and insurers must publish machine-readable files with negotiated rates. This data is what makes tools like Taven's price comparison possible.
The standard claim form used by hospitals and healthcare facilities to bill insurance companies for inpatient and outpatient services. It includes revenue codes, HCPCS codes, diagnosis codes, and charges. If you request a detailed bill from a hospital, you may receive a document based on the UB-04 format.
The amount that insurance companies consider a fair price for a medical service in your area, based on what providers typically charge. If your provider charges more than the UCR, you may owe the difference. UCR is similar to reasonable and customary and allowable charge.
A billing practice where a provider bills each component of a procedure separately instead of using a single CPT code for the entire procedure, resulting in higher total charges. Unbundling can be a billing error or, in some cases, fraudulent. If your bill has unusually many line items, let us check for unbundling.
A reduction in charges that many hospitals and providers offer to patients without health insurance. These discounts can be substantial — often 40-70% off the sticker price. Hospitals are increasingly required to offer uninsured discounts under price transparency rules. Always ask about discounts before paying full price.
The process by which your insurance company evaluates whether a medical service, procedure, or hospital stay is medically necessary and appropriate. Utilization review can happen before (pre-service), during (concurrent), or after (retrospective) treatment. It's how insurers decide whether to approve or deny coverage.
A billing practice where a provider uses a higher-level CPT code than what the service actually warrants, resulting in a larger bill. For example, billing a routine office visit as a complex evaluation. Upcoding is considered fraud and is a common reason medical bills are higher than expected. Review your bill for potential upcoding.
A healthcare delivery model where providers are paid based on patient health outcomes rather than the number of services they provide. Unlike traditional fee-for-service, value-based care rewards quality over quantity. This model is growing and can lead to better care at lower costs for patients.
A state-mandated insurance program that covers medical expenses and lost wages for employees who are injured or become ill on the job. Workers' comp is separate from your regular health insurance — your employer pays for it, and you shouldn't receive a bill for work-related injuries. If you do, something may be wrong.
An amount that a healthcare provider removes from your bill because their contract with your insurer doesn't allow them to collect it. For example, if a provider bills $500 but the allowable charge is $300, the provider "writes off" the $200 difference. You should never be billed for contractual write-offs from in-network providers.
Upload your bill and we'll translate it into plain English, flag potential errors, and show you if you're being overcharged.
Review My Bill — Free