Billing Information

Glossary of Billing Terms

Account Number - number the patient's visit (account) is given by the hospital for documentation and billing purposes.

Adjustment/Contractual Adjustment - part of the bill that the provider has agreed not to charge the patient because of billing agreements they have with the patient's insurance company.

Admitting Diagnosis - the initial medical reason that was documented for the patient's condition.

Advance Beneficiary Notice (ABN) - a notice the provider gives the patient before they receive services when Medicare is not expected to pay for some or all of the services. The notice is given so that the patient may decide whether to have the treatment and how to pay for it if Medicare denies the charges. ABNs apply to patients with traditional Medicare only.

Appeal - a process by which the patient, their provider, or the hospital can object to the health plan's decision not to pay for medical services.

Applied to Deductible - part of the bill the insurance company requires the patient to pay the provider. See also deductible.

Assignment - an agreement the patient signs that allows your insurance to pay the provider or hospital directly.

Assignment of Benefits - the provider or hospital agrees to accept payment from an insurance company first and then bill the patient for any after-insurance balances. See also benefit.

Authorization Number - a reference number stating that your treatment has been approved by insurance. Also called a certification number or prior-authorization number.

Beneficiary - someone who is covered under an insurance policy or plan.

Beneficiary/Patient Liability - the portion patients must pay out-of-pocket for medical services, including co-payments, co-insurance, and deductibles. This is in addition to the portion paid by insurance.

Benefit - the amount insurance pays for medical services.

Billed Charges - the total charges that provider send to insurance companies/patients prior to any negotiated contracts or discounts being applied.

Birthday Rule - the Birthday Rule is approved by the National Association of Insurance Commissioners (NAIC). The Birthday Rule indicates that the plan of the parent whose date of birth (month and day) falls earlier in the calendar year is the primary plan for dependent children. For example, if the mother's birth date is June 10 and the father's birth date is April 23, the father's plan would be primary. If both parents have the same birth date, the health plan in effect for the longer period of time will be primary.

Centers for Medicare and Medicaid (CMS) - the federal agency that operates the Medicare program and works with states to manage the Medicaid program (referred to as Medi-Cal in California, AHCCCS in Arizona and Medicaid in Nevada).

Certificate of Coverage (COC) - a description of the healthcare coverage included in an insurance company's plan. The certificate of coverage is required by state laws and explains the healthcare coverage provided under the contract issued to the employer.

Charity Care - free or reduced-fee health care for patients who have financial hardship.

Claim - the medical bill the provider sends to the insurance company on behalf of the patient.

Clinic - an area in a hospital or separate building that provides medical care to regularly scheduled or walk-in patients for non-emergency care.

Coding - a way provider services and supplies are classified and defined into a set of predetermined numbers/codes for the purpose of billing.

Coding of Claims - a process through which diagnoses and procedures from the patient's medical record are translated into numbers (codes) that computers can process for payment.

Co-Insurance - a type of cost sharing where the patient and insurance company share payment of the approved charge for covered services after payment of the deductible by the patient.

Collection Agency - a business that contracts with the provider to collect money from patients for unpaid bills.

Consolidated Omnibus Budget Reconciliation Act (COBRA) - a federal law that mandates employers with 20 or more eligible employees to provide continued health insurance under their group plan to terminated employees and their dependents. COBRA generally provides continued health insurance coverage for up to 18 or 36 months. COBRA beneficiaries may be required to pay 100 percent of the premium plus an administrative fee.

Coordination of Benefits (COB) - the method for determining which insurance company is primarily responsible for payment when a patient is covered under more than one insurance plan. The insured's total benefits do not exceed 100% of the medical expenses.

Co-pay - a fixed dollar amount that a patient must pay out-of-pocket. This is often associated with an office visit or emergency room visit. For example $5, $10, or $25.

Date Of Service (DOS) - the date(s) medical services were provided to the patient.

Deductible - an agreed amount that a patient must pay before the insurance company will pay anything toward medical charges. Usually the amount must be met and paid by the patient each year.

Denial - a decision by insurance company not to pay for part or all of a medical bill based on a lack of medical necessity or prior approval/certification, terminated coverage, or other reasons. Denied amounts may be charged to the patient. See also appeal.

Diagnosis Code - a code used for billing that describes the patient's illness.

Durable Medical Equipment (DME) - Medical equipment that can be used multiple times and is ordered by a doctor for use at home.

EEG - equipment or medical procedure that measures electricity in the brain.

EKG/ECG - equipment or medical procedure that measures how the heart works.

Eligibility Verification - a way providers determine whether the patient has insurance coverage for the services they will provide.

Employee Retirement Income Security Act of 1974 (ERISA) - this law regulates self-insured plans and makes them exempt from many state regulations that regulate other insurance plans. ERISA mandates financial standards and other requirements for group insurance plans.

Enrollee - person who is covered by health insurance.

Explanation of Benefits (EOB/EOMB) - the statement sent by the insurance company to the patient with a list of services provided, amount billed, and any insurance payments. This statement normally includes any payment due from the patient, such as co-insurance, deductibles, and co-payments.

Fiscal Intermediary (FI) - a private company that has a contractual relationship with Medicare to process Medicare claims.

Group Name - name of the group (usually an employer) or insurance plan that insures the patient.

Group Number - a number the insurance company uses to distinguish the group under which the patient is insured.

Guarantor - someone who either accepts or is legally responsible to pay for a given patient's bill. The guarantor may or may not be the patient.

HCFA/CMS 1500 - a billing form used by doctors to file insurance claims for medical services.

HCPCS codes - (HCFA Common Procedural Coding System) - A coding system used to describe outpatient services provided to the patient. HCPCS codes include CPT codes and other codes.

Health Care Provider - a person or entity that provides medical services (e.g. a physician, hospital or laboratory).

Health Insurance - coverage that provides for the payment of medical services as a result of sickness or injury. It includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment.

Health Insurance Portability and Accountability Act (HIPAA) - a federal law that governs standards for the security and privacy of patients' health information.

Health Maintenance Organization (HMO) - a type of insurance plan that provides coverage of designated health services needed by plan members for a fixed, prepaid premium.

Home Health Agency - an agency that offers medical care to patients in their homes.

Hospice - a group that provides inpatient, outpatient, and home health care for terminally ill patients.

Inpatient (IP) - patients who stay overnight in the hospital.

International Classification of Diseases, 9th Edition (Clinical Modification) (ICD-9-CM) - a coding system used to describe the patient's diagnosis and the procedures performed to treat them.

Long Term Care - Medical care received in a nursing home.

Medicaid - a state insurance plan, funded by federal and state agencies, for low-income people who have limited or no insurance.

Medically Necessary - refers to services or supplies that are required to properly treat a specific medical condition. Services or supplies that are not considered medically necessary by insurance may be denied.

Medicare - a federal health insurance program established for people age 65 and older. Additionally, Medicare covers some people under age 65 who have disabilities or end-stage renal disease (ESRD).

Medicare + Choice - gives Medicare patients the option of enrolling in a variety of private plans including health maintenance organizations (HMOs), preferred provider organizations (PPOs), provider-sponsored organizations (PSOs), private fee-for-service (PFFS) plans, and medical savings accounts (MSAs) with high deductible insurance plans. Under M+C plans, patients receive medical services without additional out-of-pocket costs.

Medicare Number - a number given to every Medicare patient for tracking and billing purposes. This number can be found on the Medicare card.

Medicare Part A - Medicare coverage that helps pay for inpatient hospital, home health, hospice, and skilled nursing facility services.

Medicare Part B -Medicare coverage helps pay for physician services, medical supplies, and other outpatient services not paid for by Medicare Part A.

Medicare Part D - Medicare coverage that helps pay for the costs of prescription drugs.

Medicare Summary Notice (MSN) - also called an Explanation of Medicare Benefits (EOMB). See explanation of benefits.

Medicare Supplement Policy (Medsupp) - the insurer will pay a policyholder's Medicare coinsurance, deductible and co-payments for Medicare Part A and B and may provide additional supplement benefits according to the supplement policy selected. Also called Medigap or Medicare wrap.

Medigap - additional insurance purchased by Medicare beneficiaries to cover co-payments, coinsurance, deductibles, and services not paid for by Medicare Part A or B. Also known as Medicare supplement insurance.

Network - a group of doctors, hospitals, and other health care providers that have a contract with an insurance plan to provide services to its patients.

Non-Covered Charges - charges for medical services denied or excluded by insurance. The patient may be billed for these charges. Also called "non covered amount."

Non-Participating Provider (non-par) - a doctor, hospital, or other health care entity that is not part of an insurance plan's network. For medical services rendered by non-participating provider, the patient may be responsible for payment in full or higher costs. Also known as out-of-network provider.

Out-of-Network (OON) Services - Medical services received from a non-participating provider. Coverage generally requires payment of a higher deductible, co-payment, and/or coinsurance than for medical services from a participating provider.

Out-of-Pocket (OOP) - Payment for medical services due from the patient, including copayments, co-insurance, and deductible.

Outpatient (OP) - a patient who does not need to stay overnight in a hospital. Outpatient services include lab tests, X-rays, and some surgeries.

Over-the-Counter (OTC) Drug - drugs that may be purchased at a pharmacy or drug store without prescription.

Participating Provider - a doctor, hospital, or other health care entity that is part of an insurance plan's network. They agree to accept insurance payment for covered medical services as payment in full, less any patient liability.

Point-of-Service Plan (POS) - a health insurance plan that allows the patient to choose to receive a medical service from a participating or non-participating provider, with different benefit levels with the use of participating providers.

Policy Number - a number that the insurance company assigns the patient to identify the contract for coverage.

Pre-Existing Condition (PEC) - any health condition that has been diagnosed or treated within a certain time period immediately before the patient's effective date of coverage. Pre-existing conditions may not be covered for a specified time period as noted in the insurance company's certificate of coverage (usually 6 to 12 months).

Pre-Existing Condition Exclusion - a practice of some health insurance companies to deny coverage to patients for a certain time period for medical conditions that already exist when coverage began.

Preferred Provider Organization (PPO) - an insurance plan that has contracts with healthcare providers for discounted charges. Typically, the plan offers significantly better benefits and lower costs to the patients for services received from preferred providers.

Premium -The amount paid, often in monthly payments, for an insurance policy.

Prepayment - money paid before receiving medical services.

Primary Care Physician (PCP) - a physician whose practice is devoted to internal medicine, family/general practice, pediatrics, or obstetrics/gynecology.

Primary Insurance - the insurance plan responsible for paying the bill first. If a patient is covered by another insurance, it is referred to as the secondary insurance. See also coordination of benefits.

Procedure/CPT code - a coding system used to describe medical services and surgical procedures provided to the patient.

Reasonable and Customary (R & C) - Commonly charged or prevailing fees for health services within a region or community.

Referral - approval needed for medical care beyond that offered by a primary care physician or hospital. For example, HMO plans typically require referrals from a primary care physician to see specialists.

Release of Information - a signed statement from patients or guarantors that allows physicians and hospitals to release medical information so that insurance companies can pay medical bills.

Same-Day Surgery - outpatient surgery.

Secondary Insurance - additional insurance that may pay some medical charges not covered by primary insurance. Payment is made according to the patient's insurance benefits, coverage, and coordination of benefits.

Self-Insured Plan - an insurance plan where financial responsibility for medical expenses is assumed by the group (usually an employer) rather than an insurance company. Self-insured plans are often managed by Third Party Administrators (TPA). Also known as self-funded plan.

Skilled Nursing Facility (SNF) - a facility, either free-standing or part of a hospital, that provides care to patients seeking rehabilitation and other medical care that is less intense than that received in a hospital.

Specialist - a physician who specializes in treating specific body parts and medical conditions, or certain age groups. For example, cardiologists only treat patients with heart problems.

Third Party Administrator (TPA) - an independent entity (third party) that manages group benefits, claims and administration for a self-insured company or group.

TRICARE - insurance plan for active and retired military personnel, their families, and dependents. Also known as CHAMPUS.

Usual, Customary, or Reasonable (UCR) - the amount insurance companies believe to be the common or prevailing charges for medical services provided in a region or community.

Utilization Review (UR) - a formal assessment of the medical necessity, efficiency and/or appropriateness of healthcare services provided to the patient.