Here are some common terms you will encounter when dealing with billing and insurance issues...
The maximum amount a plan pays for a covered service. See Usual and Customary Charges.
Medical services provided on an outpatient (non-hospitalized) basis.
(APC) Ambulatory Patient Classifications
A structure for classifying outpatient services and procedures for purposes of payment.
Assignment & Authorization
A form signed by the patient showing insurance plans assigned and their billing priority. This form allows the hospital to bill insurances on the patient’s behalf and receive payment directly from the payor. Signature on the form also authorizes the release of medical information to MidState Medical Center or Connecticut Children’s Medical Center, in the event the patient is transferred to one of these facilities.
These are medical services for which your insurance plan will pay, in full or in part.
Someone who is eligible for or receiving benefits under an insurance policy or plan.
A notice to the insurance company that a person received care covered by the plan. A claim is also a request for payment.
A type of cost sharing where the beneficiary and insurance provider share payment of the approved charge for covered services in a specified ratio after payment of the deductible by the insured. For example, the insurance company agrees to pay 80% of covered charges and the individual picks up 20%.
A set fee the member pays to providers at the time services are provided. Co-pays are applied to emergency room visits, hospital admissions, office visits, etc. The cost is usually minimal. The patient should be aware of the co-payment amounts prior to services being rendered.
How physician's services are identified and defined.
Consolidated Omnibus Budget Reconciliation Act (COBRA)
A federal law that requires employers to offer continued health insurance coverage to certain employees and their beneficiaries whose group health insurance coverage has been terminated. Applies to employers with 20 or more eligible employees. Typically, COBRA makes continued coverage available for up to 18 or 36 months. COBRA enrollees may be required to pay 100 percent of the premium, plus an additional 2 percent.
Integrating benefits payable under more than one health insurance (for example, Medicare and retiree health benefits). Coordinated coverage is typically arranged so the insured benefits from all sources not exceeding 100 percent of allowable medical expenses. Coordinated coverage may require beneficiaries to pay some deductible or co-insurance.
Coordination of Benefits (COB)
A provision that applies when a person is covered under more than one group medical program. (See "Coordinated Coverage" above.)
What services the health plan does and does not pay for.
What the insurance company will consider paying for as defined in the contract. For example, under some plans generic prescriptions are covered expenses while brand name prescriptions are not.
Date Of Service (DOS)
The date(s) healthcare services were provided to the beneficiary.
A portion of the covered expenses (typically $100, $200 or $500) that an insured individual must pay before insurance coverage with co-insurance goes into effect. Deductibles are standard in many policies, and are usually based on a calendar year.
Diagnosis-Related Groups (DRGs)
The hospital classification and reimbursement system that groups patients by diagnosis, surgical procedures, age, sex and presence of complications. This is a financing mechanism used to reimburse hospital and selected other providers for services rendered.
Duplicate Coverage Inquiry (DCI)
A request to an insurance company or group medical plan by another insurance company or medical plan to find out whether other coverage exists (see Coordinated Coverage).
Durable Medical Equipment (DME)
Medical equipment which: can withstand repeated use; is not disposable; is used to serve a medical purpose; is generally not useful to a person in the absence of sickness or injury, and is appropriate for use in the home. Examples include hospital beds, wheelchairs and oxygen equipment.
Employee Retirement Income Security Act of 1974 (ERISA)
This law mandates reporting, disclosure of grievance and appeals requirements and financial standards for group life and health. Self-insured plans are regulated by this law.
The person who is covered by health insurance.
Exclusive Provider Organization (EPO)
Arrangement consisting of a group of providers who have a contract with an insurer, employer, third party administrator or other sponsoring group. Criteria for provider participation may be the same of those in PPOs but have a more restrictive provider selection and credentialing process.
Any health care services, that are determined by the insurance plan to be either; not generally accepted by informed health care professionals in the United States as effective in treating the condition, illness or diagnosis for which their use is proposed; or not proven by scientific evidence to be effective in treating the condition for which it is proposed.
Explanation of Benefits (EOB)
The coverage statement sent to covered persons listing services rendered, amount billed and payment made. This normally would include any amounts due from the patient, as described in "Beneficiary Liability," "Co-insurance," "Deductible" and "Co-payment" all listed above.
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Health Care Provider
An individual or institution that provides medical services (e.g. a physician, hospital or laboratory). This term should not be confused with an insurance company that "provides" insurance.
Coverage that provides for the payment of benefits as a result of sickness or injury. Includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment.
Health Insurance Portability and Accountability Act (HIPAA)
Federal legislation to provide easier portability of medical information by standardizing electronic transaction and code sets, and enacting additional patient privacy provisions. Scheduled to take effect April 2003.
Health Maintenance Organization (HMO)
An entity that provides, offers or arranges for coverage of designated health services needed by plan members for a fixed, prepaid premium.
Hospital Inpatient Prospective Payment System (PPS)
Medicare's method of paying acute care hospitals for inpatient care. Prospective per-case payment rates are set at a level intended to cover operating costs for treating a typical inpatient in a given DRG.
A federal program jointly funded by states and the federal government, which provides medical insurance coverage for children not covered by state Medicaid-funded programs.
International Classification of Diseases, 9th Edition (Clinical Modification) (ICD-9-CM)
A listing of diagnosis and identifying codes used by physicians and hospitals for reporting diagnoses and procedures of health plan enrollees.
Maximum Out of Pocket
The most money you can expect to pay for covered expenses. The maximum limit varies from plan to plan. Once the maximum out-of-pocket has been met, the health plan will pay 100% of certain covered expenses.
A jointly-funded, Federal-State health insurance program for certain low-income and needy people. It covers approximately 36 million individuals including children, the aged, blind, and/or disabled, and people who are eligible to receive federally assisted income maintenance payments.
A federal health benefit program for people over 65 and disabled that covers 35 million Americans - or about 14% of the population - for an annual cost of over $120 billion. Medicare pays for 25% of all hospital care and 23% of all physician services.
Medicare Benefits Notice
A notice you get after your doctor files a claim for Part A services in the Original Medicare Plan. It says what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay. You might also get an Explanation of Medicare Benefits (EOMB) for Part B services or a Medicare Summary Notice (MSN).
Made up of two parts: Hospital Insurance (Part A) and Medical Insurance (Part B). (See Medicare Part A (Hospital Insurance); Medicare Part B (Medical Insurance).)
Medicare Part A (Hospital Insurance)
Hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care.
Medicare Part B (Medical Insurance)
The part of Medicare that covers doctors' services and outpatient hospital care. It also covers other medical services that Part A does not cover, like physical and occupational therapy.
Medicare Secondary Payer
A statutory requirement that private insurers providing general health insurance coverage to Medicare beneficiaries pay beneficiary claims as primary payers.
Medicare Supplement Policy (Medsupp)
The insurer will pay a policyholder's Medicare co-insurance, deductible and co-payments for Medicare Part A and B and may provide additional supplement benefits according to the supplement policy selected.
Privately purchased individual or group health insurance policies designed to supplement Medicare coverage. Benefits may include payment of Medicare deductibles, co-insurance and balance bills, as well as payment for services not covered by Medicare.
Purchased by Medicare enrollees to cover co-payments, deductibles and healthcare goods or services not paid for by Medicare. Also known as a Medicare supplements policy.
A privately purchased insurance policy that supplements Medicare coverage.
Physicians, hospitals, and other health care providers that an HMO, PPO or other managed care network has selected to provide care for its members.
Non-Participating Provider (Non-par)
Also known as out-of-network provider. A healthcare provider who has not contracted with the carrier of a health plan to be a participating provider of health care.
A specified period of time in which employees may change insurance plans and medical groups offered by their employer and have the new insurance effective at a later date.
Out of Network (OON)
Coverage for treatment obtained from a non-participating provider. Typically, it requires payment of a deductible and higher co-payments and co-insurance than for treatment from a participating provider. Insurer may also deny entire bill.
The portion of payments for covered health services required to be paid by the patient, including co-payments, co-insurance and deductible. (See "Beneficiary Liability," "Co-insurance," "Deductible" and "Co-payment" above.)
Pre-Admission Certification (PAC)
A review of the need for inpatient hospital care, completed before the actual admission.
A provider who has contracted with the health plan to deliver medical services to covered persons. The provider may be a hospital, pharmacy or other facility or a physician who has contractually accepted the terms and conditions as set forth by the health plan.
Medical Hospital Insurance (HI) under part A of title XVIII of Social Security Act, which covers patients for inpatient hospital, home health, hospice and limited skilled nursing facility services. Beneficiaries are responsible for deductibles and co-payments.
Medicare Supplement Medical Insurance (SMI) under Part B of Title XVII of the Social Security Act, which covers Medicare beneficiaries for physician services, medical supplies and other outpatient treatment. Beneficiaries are responsible for monthly premiums, co-payments, deductibles and balance billing.
Point-of-Service Plan (POS)
Managed care product that offers enrollees a choice among options when they need medical services, rather than when they enroll in the plan. Enrollees may use providers outside the managed care network, but usually at higher cost. (This should not be confused with POS as used in retail pharmacy, where it stands for point of sale.)
An insurance plan requirement in which you or your primary care physician need to notify your insurance company in advance about certain medical procedures (like outpatient surgery) in order for those procedures to be considered a covered expense.
Authorization given by a health plan for a Member to obtain services from a health care provider, most commonly required for hospital services. Members should refer to their insurance identification card or call their health plan to obtain information regarding pre-certification requirements.
Pre-Existing Condition (PEC)
Any medical condition that has been diagnosed or treated within a specified period immediately preceding the covered person's effective date of coverage. Pre-existing conditions may not be covered for some specified amount of time as defined in the certificate of coverage (usually six to 12 months). Individuals can be required to satisfy a pre-existing waiting period only once, so long as they maintain continuous group health plan coverage with one or more carriers.
Pre-Existing Condition Exclusion
A practice of some health insurers to deny coverage to individuals for a certain period for health conditions that already exist when coverage is initiated.
Preferred Provider Organization (PPO)
A program that establishes contracts with providers of medical care. Providers under such contracts are referred to as a preferred provider. Usually, the benefit contract provides significantly better benefits and lower member costs for services received from preferred providers, thus encouraging covered persons to use these providers.
Amount paid periodically to purchase health insurance benefits.
Primary Care Network (PCN)
A group of primary care physicians who have joined together to share the risk of providing care to their patients who are covered by a given health plan.
Primary Care Physician (PCP)
A physician, the majority of whose practice is devoted to internal medicine, family/general practice and pediatrics. An obstetrician/gynecologist sometimes is considered a primary care physician, depending on coverage.
A fee is considered "Reasonable" if it is both usual and customary or if it is justified because there is a complex problem involved.
Approval or consent by a primary care physician for patient referral to ancillary services and specialists.
An insurance policy, plan, or program that pays second on a claim for medical care. This could be Medicare, Medicaid, or other health insurance depending on the situation. For Commercial or Managed payors, if you have additional coverage through your spouse, then coverage through their insurance will be considered your secondary. For children covered under two insurance plans, primary coverage will be determined by the Subscriber (Mom or Dad) whose month of birth is closest to the beginning of the year. This is also known as the Birthday Rule.
Skilled Nursing Facility
A facility (which meets specific regulatory certification requirements) which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.
A physician who specializes in a specific area of medicine, such as cardiology, oncology, urology, etc. Most HMOs require members to obtain a Referral from their Primary Care Physician before setting an appointment to see a Specialist.
Usually described as a comprehensive inpatient program for those who have experienced a serious illness, injury or disease, but who do not require intensive hospital services. The range of services considered sub-acute can include infusion therapy, respiratory care, cardiac services, wound care, rehabilitation services, post-operative recovery programs for knee and hip replacements, cancer, stroke and AIDS care.
The person responsible for payment of premiums or whose employment is the basis for eligibility for membership in an HMO or other health plan.
Supplementary Medical Insurance
The Medicare program that pays for a portion of the costs of physicians' services, outpatient hospital services, and other related medical and health services for voluntarily insured aged and disabled individuals. Also known as Part-B
Third Party Administrator (TPA)
An independent person or corporate entity (third party) that administers group benefits, claims and administration for a self-insured company or group.
Usual, Customary and Reasonable (UCR)
A term used to refer to the commonly charged or prevailing fees for health services within a geographic area.
Utilization Review (UR)
Programs designed to reduce unnecessary medical services, both inpatient and outpatient. Utilization reviews may be prospective, retrospective, concurrent, or in relation to discharge planning.
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