PPO Participant Education Brochure
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Health Care Glossary

Balance Billing - The process of a provider trying to collect from a patient, the PPO Discount, the difference between what is allowed per the 4MOST contract and what they normally charge. Balance Billing is not permitted when a 4MOST member and a Network provider are involved.

Benefit Plan - An entity that pays claims; which can either be an insurance company third party administrator or the employer itself. 4MOST Health Network is not a Benefit Plan.

Co-payment - Some plans have a benefit where there is a set amount you pay when
visiting certain providers. This amount is the Co-payment.

Gatekeeper - A primary care physician who must give you a referral when you want to
see a specialist or other health care provider. 4MOST does not use a Gatekeeper system;
members are free to visit any provider they wish.

Managed Care - The process of controlling health care costs while helping to ensure the
quality of care.

Network - Used to describe providers who are participating in the 4MOST Health
Network.

Precertification - Notification to a Benefit Plan advising them that you are seeking certain types of medical treatment.

Preferred Provider - Network hospitals and physicians who will provide a range of healthcare services for discounted fees specified in a formal contract and performed according to agreed upon standards.

Up-front Billing - When a provider tries to collect for services rendered before the bill is
submitted to a payor. Up-front Billing is not allowed by Network providers.