Thrizer Insurance Definitions
Last Updated: 2026-04-02 Status: CanonicalPurpose: Provides canonical definitions for insurance terms used across Thrizer. Use this file when a query requires precise meaning, interpretation, or disambiguation of insurance terminology (e.g., deductible, allowed amount, coinsurance, claim status, reimbursement). Route here for: Term definitions or clarification of insurance concepts Understanding relationships between financial inputs (provider fee, allowed amount, deductible, coinsurance) Interpreting claim statuses, outcomes, or result types Explaining how estimates (reimbursement, out-of-pocket) are constructed at a conceptual level Do not use this file for: Product behavior, workflows, or user actions Pricing rules, fee calculations, or payout timing Insurer-specific policies or plan details Determining actual claim outcomes or guarantees All interpretations derived from this file must respect global constraints: insurance carriers control claim decisions, reimbursement amounts, and deductible application; all estimates are non-guaranteed.
Global Constraints
- Insurance carriers determine claim outcomes.
- Insurance carriers determine reimbursement amounts.
- Insurance carriers determine deductible application.
- Insurance carriers determine claim approval or denial.
- Coverage estimates and reimbursement estimates are not guarantees.
Core Financial Inputs
Provider Fee
DefinitionThe provider fee is the therapist’s full session rate charged for a service.
Allowed Amount
DefinitionThe maximum amount recognized by the insurer for a covered service. Source
- Determined by the insurer after claim adjudication
- Thrizer may estimate the allowed amount prior to claim submission for pricing and reimbursement estimates
- These estimates are replaced with actual allowed amounts after adjudication
Insurance reimbursement calculations are based on the allowed amount, not the provider fee. Rule
If provider_fee > allowed_amount, the client may be responsible for the difference between provider_fee and allowed_amount.
Deductible
DefinitionThe deductible is the cumulative amount a client must pay out of pocket before insurance begins reimbursing eligible claims. Rule
When deductible_status = Unmet, the allowed_amount may be applied toward the deductible. Rule
When deductible_status = Unmet, reimbursement_amount may equal 0 even if the claim is approved. Rule
When deductible_status = Unmet, client responsibility may include:
- allowed_amount applied to deductible
- any difference between provider_fee and allowed_amount
Deductible Status
DefinitionDeductible status indicates whether the client has met the deductible at the time of claim processing. Canonical Values
- Met
- Unmet
Coinsurance Rate
DefinitionThe coinsurance rate is the percentage of the allowed amount assigned to the client after the deductible is met.
Derived Financial Concepts
Coinsurance
DefinitionCoinsurance is the portion of the allowed amount the client is responsible for after the deductible is met. Condition
Applies only when deductible_status = Met Rule
Coinsurance is calculated from the allowed amount, not the provider fee.
Estimated Reimbursement
DefinitionEstimated reimbursement is a predicted insurance payment amount for a service. Normalized Inputs
- allowed_amount
- deductible_status
- coinsurance_rate
Estimated reimbursement is not guaranteed.
Estimated Out-of-Pocket Responsibility
DefinitionEstimated out-of-pocket responsibility is the predicted amount the client pays for a service. Formula
provider_fee − estimated_reimbursement Constraint
Estimated out-of-pocket responsibility is not guaranteed.
Coverage
Out-of-Network Benefits
DefinitionOut-of-network benefits are insurance coverage for services provided by non-contracted providers. Constraint
The presence of out-of-network benefits does not guarantee reimbursement. Constraint
Out-of-network benefits vary by insurance plan.
Coverage Estimates
DefinitionCoverage estimates are predicted reimbursement and cost values based on benefit information available at the time of verification. Constraint
Coverage estimates are not guarantees.
Claims
Insurance Claim
DefinitionAn insurance claim is a submission requesting reimbursement or deductible credit for a healthcare service.
Claim Data Elements
DefinitionAn insurance claim contains structured data required for processing. Typical Fields
- client_identifier
- provider_identifier
- service_code
- billed_amount
- diagnosis_code
- insurance_plan_identifier
Claim Status
DefinitionClaim status represents the processing state of a claim. Canonical Status Values
- Processing
- Investigating
- Approved
- Denied
Claim Result
DefinitionClaim result represents the financial outcome of a processed claim. Possible Outputs
- reimbursement_amount
- deductible_applied_amount
- payment_method
Claim Outcome Types
DefinitionClaim outcome types represent final financial classifications of a processed claim.
Reimbursed
DefinitionInsurance pays a portion of the allowed amount.
Applied to Deductible
DefinitionReimbursement amount = 0 and allowed_amount is applied to deductible. Condition
Typically occurs when deductible_status = Unmet
Denied
DefinitionNo reimbursement is issued and no deductible application occurs.
Claim Outcome Rules
RuleApproved means the insurance carrier approved the claim for processing. Approved does not by itself determine whether the claim was reimbursed or applied to deductible. Deductible application and reimbursement are separate financial outcomes. Rule
A claim may be approved and still result in reimbursement_amount = 0.