Insurance Dictionary

Prior authorization, Precertification, Prior Approval, or Predetermination: A process by which your gender care provider sends your referral for surgery to your insurance company to determine the extent in which they will cover it; however, if this is sent without all of the required criteria it may automatically be declined.  As each insurance company and plan has different requirements, you have to call and clarify what your provider needs to include and notify them.

CPT Code: A series of 5 numbers used to represent a specific medical procedure. Helpful chart below.

NPI: National provider identifier, a number that identifies healthcare providers to government and insurance companies, these are listed online here.

Diagnosis code: also called ICD 10 codes, they are the reason for surgery. Usually, this code is F64.9 Gender Identity Disorder. Some insurances exclude coverage for trans health care. If you have another reason for the surgery, you may try a different code.

Deductible:  The amount you pay out of pocket before your insurance starts paying. For instance, if you have a $2,000 deductible, you will pay for most all my healthcare expenses until you’ve spent $2,000. This often excludes things that are considered “preventative care” likely a yearly check-up.

Out-of-Pocket Maximum:  This is the most you’ll pay toward your healthcare in a given year. Let’s say you have an insurance plan with an out-of-pocket maximum of $5,000, once you’ve reached that amount, the insurance company picks up 100% of the costs for the rest of the plan year (excluding co-pays).

Co-pay:  A small fee you pay each time you use a specific service – this fee doesn’t go toward meeting your deductible. For instance, some insurance plans have a $20 (or higher) co-pay for a doctor visit that isn’t preventive care (like an ear infection or the flu).

Co-insurance: Some plans have you pay a portion of your expenses after the deductible is met. For instance, I might have a $2,000 deductible, so I’m paying 100% of the costs until I’ve spent $2,000. If my plan has 20% co-insurance, it means the insurance company picks up 80% of the costs, and I pay the other 20% (until I hit the out-of-pocket maximum amount)

In-Network:   This is your insurance company’s approved list of doctors or providers. They’ve negotiated lower costs with these doctors, so if you use them, you’re considered “In-Network” and your costs are lower, too.

Out–of–Network:  These are doctors or providers that aren’t on your insurance company’s approved list. If you choose one of these doctors, there are no negotiated prices, so you’ll pay more.

Denials: If your insurance company denies coverage for a procedure, you can APPEAL the denial. You should receive a letter stating the reasons for your coverage denial and information on how to appeal that decision. Often, you can start the appeals process by calling and requesting an appeal. IF they deny twice, usually an outside agency will review and that may get you the coverage you need.