Short answer
Insurance language can be confusing, especially when you are trying to understand what you may pay or what insurance may reimburse. This glossary explains common insurance and payment terms you may see in Thrizer. These definitions are meant to help you understand the process. They do not guarantee what your insurance plan will cover or pay. Insurance carriers determine final coverage, claim approval, reimbursement amounts, deductible application, and claim outcomes.Payment types
Thrizer Pay
Thrizer Pay is a payment type where an eligible client pays an estimated out-of-pocket amount at the time of service instead of paying the full session fee upfront. Thrizer advances the remaining portion of the session fee to the clinician. Because Thrizer advances that amount, any insurance reimbursement for that claim is routed to Thrizer. The client’s upfront amount is based on available insurance and claim information. Because it is an estimate, the final amount may differ after insurance processes the claim.OON Pay
OON Pay is a payment type where the client pays the full session fee upfront and Thrizer submits the out-of-network insurance claim. If insurance reimburses the claim, the reimbursement is sent back to the client through Thrizer. With OON Pay, reimbursement depends on the insurance carrier’s final processing decision.Self-Pay
Self-Pay means no insurance claim is submitted through Thrizer. The client pays for the service without using Thrizer for insurance claim submission or reimbursement.Cost and reimbursement terms
Provider fee
The provider fee is the full session rate charged for a service. Insurance reimbursement is not always based on the full provider fee. Insurance may use a different amount, called the allowed amount, when calculating reimbursement.Allowed amount
The allowed amount is the maximum amount an insurance plan recognizes for a covered service. Insurance reimbursement is based on the allowed amount, not necessarily the provider fee. If the provider fee is higher than the allowed amount, the client may be responsible for the difference. Before a claim is processed, the allowed amount may be estimated. After the claim is processed, the final allowed amount is determined by the insurance carrier.Deductible
A deductible is the amount a client must pay out of pocket before insurance begins reimbursing eligible claims. If the deductible has not been met, an approved claim may still result in $0 reimbursement. In that case, the allowed amount may be applied toward the deductible instead of being paid back to the client.Deductible status
Deductible status means whether the deductible has been met or not met at the time the claim is processed. Deductible status may first be estimated from benefit information. After a claim is approved, deductible status may be updated based on the insurer’s claim result.Coinsurance
Coinsurance is the portion of the allowed amount that the client is responsible for after the deductible is met. Coinsurance is calculated from the allowed amount, not the provider fee.Estimated reimbursement
Estimated reimbursement is a predicted insurance payment amount based on available information. It is not guaranteed. The final reimbursement amount is determined by the insurance carrier after the claim is processed.Estimated out-of-pocket responsibility
Estimated out-of-pocket responsibility is a predicted amount the client may pay for a service. This estimate is usually based on available insurance information, including deductible status, coinsurance, and estimated reimbursement. It is not guaranteed.Reimbursement
Reimbursement is the amount paid by an insurance carrier after claim processing. Reimbursement may be sent to the client or routed according to the payment type being used. The amount and timing are determined by insurance processing.Claims terms
Insurance claim
An insurance claim is a submission to an insurance company requesting reimbursement or deductible credit for a healthcare service. A claim usually includes information about the client, provider, service, billed amount, diagnosis code, and insurance plan.Claim status
Claim status is the current processing state of a claim. Common claim statuses are:- Processing
- Investigating
- Approved
- Denied
Claim result
Claim result describes the financial outcome of a processed claim. A claim result may include information such as reimbursement amount, deductible credit, or payment method.Reimbursed
A claim is reimbursed when insurance pays a portion of the allowed amount. The reimbursement amount is determined by the insurance carrier.Applied to deductible
Applied to deductible means the claim was approved, but the reimbursement amount was $0 because the allowed amount was applied toward the client’s deductible. This commonly happens when the deductible has not been met.Denied
Denied means the insurance carrier did not approve the claim for reimbursement or deductible credit. If a claim is denied, reimbursement is $0 and no deductible amount is applied.Coverage and benefit terms
Out-of-network benefits
Out-of-network benefits are insurance benefits for services provided by providers who are not contracted with the client’s insurance plan. Having out-of-network benefits does not guarantee reimbursement. Coverage and reimbursement vary by plan and are determined by the insurance carrier.Coverage estimate
A coverage estimate is a predicted reimbursement or cost value based on benefit information available at the time of verification. Coverage estimates are not guarantees. Final claim outcomes are determined by the insurance carrier.Primary insurance on file
Primary insurance on file means the client’s insurance has been verified within Thrizer. This does not guarantee specific coverage details, reimbursement amounts, or payment type availability.Eligibility
Eligibility means the client’s insurance has been confirmed through a usable benefit check. Eligibility does not determine coverage details, reimbursement amounts, or which payment types are available. Those depend on other rules and insurer processing.Usable benefit check
A usable benefit check means Thrizer has received enough benefit information to support claim workflows and reimbursement estimates. A usable benefit check can help estimate costs, but it does not guarantee final reimbursement or claim approval.Successful claim
A successful claim is a processed claim that results in either reimbursement or deductible application. A successful claim helps confirm how insurance handled the claim, but future claims may still depend on the insurance carrier’s rules and processing.Why estimates can change
Estimates are based on the information available before insurance finishes processing the claim. Final outcomes may differ because the insurance carrier determines:- the allowed amount
- whether the claim is approved or denied
- how much applies to the deductible
- whether reimbursement is issued
- the final reimbursement amount
Related articles
Deductibles, coinsurance, and allowed amounts
Learn how deductible status, coinsurance, and allowed amounts affect what a client may pay or receive back.
Reimbursement basics
Understand how out-of-network reimbursement works and why insurance determines the final amount.
Why an approved claim may not pay reimbursement
Learn why an approved claim can still result in $0 reimbursement when deductible rules apply.
Why reimbursement can differ from an estimate
See why estimated reimbursement may change after insurance processes a claim.
Which payment types are available?
Compare Self-Pay, OON Pay, and Thrizer Pay in plain language.