The maximum amount a plan will pay for a covered health care service. May also be called "payment allowance", or "negotiated rate".

The amount the insured individual pays, as a set percentage of the cost of covered services, as an out-of-pocket payment to the provider. Example: Insured pays 20% and the insurer pays 80%.

A fixed amount ($20, for example) the insured individual pays for a covered health care service after the deductible is paid.

The amount the insured individual pays for covered health care services before the insurance plan starts to pay.

Amount of the charge which is considered for adjudication.

The amount of the member's liability.

The portion of the cost of the service that was deemed not eligible by the insurer because the service or member was not covered by the subscriber contract.

The most the insured individual has to pay for covered services in a plan year. After this amount is spent on deductibles, copayments, and coinsurance for in-network care and services, the health plan pays 100% of the costs of covered benefits.

A medical visit means diagnostic, therapeutic, or consultative services provided to a client by a healthcare professional in an outpatient setting.

Benefit penalty is an approach used by the insurance company to reduce their payment on a claim when the patient or medical provider does not satisfy the rules of the health plan. Benefit penalties may occur when a pre-authorization is not obtained, for example.