GHI PPO/EPO and PPO/EPO Share - EmblemHealth

Important DefinitionsThis handbook may contain some phrases or terms that you are not familiar with. The followingdefinitions may assist you in understanding terms applicable to your coverage.Allowed charge: The amount GHI will reimburse for covered services rendered by Non-NetworkProviders. Allowed charges are determined differently depending upon your specific planand the type of service rendered. For many medical services rendered by Non-Network Providers,allowed charges are based on a percentile of either the FAIR Health schedule, or the publishedrates allowed by Medicare. In some cases, the allowed charge may be a percentage of the provider’ssubmitted charge. Please refer to your Certificate of Insurance, Certificate Attachment, andRiders for more details regarding how allowed charges are determined on your specific plan.Annual maximum: The maximum accumulated payments GHI will make for covered servicesrendered to a covered person during a calendar year, or the maximum number of covered days/visits available to a covered person for a particular service or services during a calendar year.Adverse determination: A determination by GHI or its agents that an admission, extension ofstay, or other health care service has been reviewed and, based on the information provided, is notmedically necessary, or is experimental or investigational in nature, and therefore not covered.Balance-of-charges: Non-Network Providers have not agreed to accept GHI’s allowed charge aspayment in full. When you receive out-of-network services, you are responsible for any providercharges that exceed GHI’s allowance in addition to any copayment, deductible, and/or coinsuranceamounts that apply to your benefits for covered services. For example, if the provider charges$50 for a given service and GHI allows $30, then you are responsible for the $20 difference($50 - $30 = $20) in addition to any cost-sharing provisions that apply to your coverage.Certificate attachment: The attachment is a specification page that provides important informationabout your GHI health insurance. It sets forth the types of services for which you arecovered. It sets forth any copayments, deductibles, and other maximums that apply to yourcoverage. It advises you of the Schedule(s) of Allowances and reimbursement terms that applyto covered services. It advises you whether or not you are covered for services rendered by Non-Network Providers. It also provides eligibility information about certain types of dependents.Certificate of insurance: Document(s) evidencing the health insurance coverage providedunder the Group Contract between GHI and your group.Coinsurance: Coinsurance is a percentage of GHI’s allowance(s) payable by you for coveredservices. Expenses credited toward your deductible, copayments, charges for services that are notcovered, and charges in excess of GHI’s allowances and benefit limitations are also payable byyou, but are not considered to be coinsurance.Back to Tableof ContentsDownloadClaim FormsRegister at ​ghi.comDirectory of HealthCare Providers34