Your charges for a medical visit.
The number assigned by your provider (hospital, physician, home care service, etc.) when medical services were provided.
The amount of money a doctor or supplier charges for a certain medical service or supply. This amount is often more than the amount an insurance plan approves.
The portion of your bill that your provider has agreed to write off.
The date admitted for treatment.
The hour when you were admitted for inpatient or outpatient care.
Words or phrases your doctor uses to describe your condition.
A notice your provider gives you before you are treated, informing you that Medicare will not pay for the treatment or service. The notice is given to you so that you may decide whether to have the treatment and how to pay for it.
A written document prepared in advance that says how you want medical decisions to be made if you lose the ability to make decisions for yourself. A healthcare advance directive may include a Living Will and a Durable Power of Attorney for healthcare.
A formal medical billing term that refers to insurance claims that have not been paid or balances owed by patients overdue by more than 30 days. Aging claims may become denied if they are not filed in time with a health insurance company.
A payment covering all services during your hospital stay.
Determined by your insurance to be the amount your provider is due for a particular service. This amount is usually less than the amount billed by the provider and is determined by pre-negotiated contracts or regulations.
Care provided in the doctor’s office or surgical center on an outpatient basis, without an overnight stay.
A Medicare payment system that classifies outpatient services so Medicare can pay all hospitals the same amount.
Outpatient surgery or surgery that does not require an overnight hospital stay.
The largest organization of physicians in the U.S. dedicated to improving the quality of healthcare administered by providers across the country. The AMA maintains and revises the Current Procedural Terminology (CPT) code set in accordance with federal guidelines.
How much your doctor or hospital bills you.
What your insurance company does not pay, including deductibles, co-insurances and charges for non-covered services.
The dollar amount that you paid for your doctor or hospital visit.
How much your insurer pays for your treatment, minus any deductibles, coinsurance, or charges for non-covered services.
The inpatient services you receive beyond room and board charges, such as laboratory tests, therapy, surgery, etc.
Drugs given to you during surgery to eliminate or reduce surgical procedure pain.
A process by which you, your doctor or your hospital, can object to your health plan when you disagree with the health plan’s decision to deny payment for your care.
A digital network that allows healthcare providers to access quality medical billing software and technologies without needing to purchase and maintain it themselves. Providers who use ASP typically pay a monthly fee to the company that maintains the billing software.
A portion of your bill, as defined by your insurance company, that you owe your provider.
An agreement you sign that allows your insurance to pay the doctor or hospital directly.
An agreement you sign that allows your insurance to pay the provider directly.
The doctor who orders your treatment and who is responsible for your care.
The approval of care, such as hospitalization, by an insurer or health plan. Your insurer or health plan may require pre-authorization before you are treated.
A number stating that your treatment has been approved by your insurance plan. Also called a Certification Number, Prior Authorization Number or Treatment Authorization Number.
The amount owed to the provider indicated on the billing statement.
How much doctors and hospitals charge you after your health plan, insurance company, or Medicare have paid their approved amount.
The practice of a provider billing you for all charges not paid by your insurance plan, even if those charges are above the plan’s usual, customary and reasonable (UCR) charges or are considered medically unnecessary.
A person covered by health insurance.
A way providers can retrieve information about whether you have insurance coverage.
A statement that you are responsible for some treatments or charges.
The amount your insurance company pays for medical services.
The legal agreement between a health plan and you. This contract establishes the full range of benefits available to you through your healthcare plan.
The extent to which your insurance coverage will pay for services provided to you.
A printed summary of your medical bill.
The person designated to receive the monthly billing statements. This person can coordinate the billing, payment and insurance coverage for the account.
A summary of current activity on an account, sent to patients or guardians updating them regarding the status of their claim.
Endorsed by the National Association of Insurance Commissioners (NAIC), this rule states 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.
A federation of 38 health insurance companies in the U.S. that offer health insurance options to eligible persons in their area, providing healthcare plans to over 100 million people.
Drugs made and sold by a major drug company. Brand-name drugs may or may not be listed on a formulary.
A fixed payment that a patient makes to a health insurance company or provider to recoup costs incurred from various healthcare services. A capitation is different from a deductible or co-pay.
Charges for heart procedures, such as heart catheterization and stress testing.
A way to help you get the care you need, especially when you need pre-authorized care from several services. Usually, a nurse helps arrange for your care.
Charges equal to the gross charge, applicable when you do not qualify for any hospital financial assistance programs.
The federal agency that runs the Medicare program. In addition, CMS works with the states to run the Medicaid programs.
The official authorization for use of services.
A number stating that your treatment has been approved by your insurance plan. Also called an Authorization Number, Prior Authorization Number or Treatment Authorization Number.
Insurance linked to military service. ChampVA/CHAMPUS (now known as TRICARE) shares the cost of certain medically necessary procedures and supplies with eligible beneficiaries.
Free or reduced-rate care provided to patients who have financial hardship.
Your medical bill that is sent to an insurance company for payment.
A number assigned by your insurance company to an individual claim.
The review your insurer or health plan performs before paying your provider or reimbursing you. This review allows the insurer to validate the medical appropriateness of the services given and review the charges related to your care.
A claim that does not have to be investigated by insurance companies before they process it — one that is free of errors and processed in a timely manner.
Facilities that review and correct medical claims as necessary before sending them to insurance companies for final processing. This editing process for claims is known as ‘scrubbing.’
An area in a hospital or separate building that treats regularly scheduled or walk-in patients for non-emergency care.
A federal law that protects employees and their families in certain situations by allowing them to keep their existing health insurance for a specified amount of time after job loss.
The process of translating a physician’s documentation about a patient’s medical condition and health services rendered into medical codes that are then entered into a claim for processing with an insurance company.
Translating clinical information from your medical record into numbers (such as diagnosis and procedure codes) that insurance companies use to pay claims.
The amount you must pay after your insurance has paid its portion, according to your Benefit Contract. In many health plans, patients must pay for a portion of the allowed amount.
Hospital inpatient Medicare coverage from day 61 to day 90 of continuous hospitalization. You are responsible for paying for part of those days. After the 90th day, you enter your Lifetime Reserve Days.
A business that collects money for unpaid bills.
The ratio of payments received relative to the total amount owed to providers.
Commercial health insurance is typically an employer-sponsored or privately purchased insurance plan. Commercial plans are not maintained or provided by any government-run program.
Conditions due to pregnancy, labor, and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a non-emergency caesarean section generally are not complications of pregnancy.
An agreement you sign that gives you permission to receive medical services or treatment from doctors or hospitals.
A part of your bill that your doctor or hospital must write off because of billing agreements with your insurance company.
A predetermined, fixed fee that you pay at the time of service. Copayment amounts vary by service and may vary depending on which provider you see.
A feature or program within an insurance plan whereby a manufacturer’s payments do not count toward the patient’s deductible and out-of-pocket maximum.
A program offered by drug manufacturing companies as a direct way to lower out-of-pocket costs for eligible patients.
A feature or program within an insurance plan whereby the maximum value of the manufacturer’s copay card or coupon is applied evenly throughout the benefit year.
How insurance companies work together when you have more than one insurance plan, to prevent double payment for your care.
Routine charges for care you receive in a heart center because you need more care than you can get in a regular medical unit.
The division of healthcare expenses between the insurance provider and the policyholder, generally including deductibles, coinsurance, and copayments.
An agreement you sign that gives you permission to receive medical services or treatment from doctors or hospitals.
Discounts that reduce the amount you pay for certain services covered by an individual plan you buy through the Marketplace. You may get a discount if your income is below a certain level.
Services that your insurance company pays for in full or in part.
Services that are typically covered under the terms of your contract with your insurance company, often subject to your deductible and coinsurance.
The days that your insurance company pays for in full or in part.
A 5-digit numbering system that helps standardize professional and outpatient facility billing. There is a CPT code for certain types of medical services.
When the provider may owe a refund to the patient or insurance plan, dependent upon review of the account.
The application process for a provider to coordinate with an insurance company. Once providers are credentialed with an insurance company, they can work with that company to provide affordable healthcare to patients.
When claim information is sent from a primary insurance carrier to a secondary insurance carrier, or vice versa.
A type of X-ray of the head or body, usually done in a hospital’s X-ray department.
Bill preparation date. It is not the same date as the date of service.
Treatment date.
A document that summarizes the services, treatments, payments, and charges that a patient received on a given day.
The total number of days that you are being charged for the hospital’s services.
The highest charge that a hospital has negotiated with all health plans for an item or service.
The amount a patient pays before the insurance plan pays anything. In most cases, deductibles apply per person per calendar year.
The patient’s information required for filing a claim, such as age, sex, address, and family information. An insurance company may deny a claim if it contains inaccurate demographics.
A service for which your healthcare plan has determined the provisions of your benefit plan do not have benefits available. If your insurance denies benefits for a service, you are liable for the entire amount.
Tells what your doctor or hospital did for you.
A code used for billing that describes your illness.
A payment system used by many insurance companies for inpatient hospital bills. This system categorizes illnesses and medical procedures into groups. Hospitals are paid a fixed amount for each admission.
Tests to figure out what your health problem is. For example, an X-ray can be a diagnostic test to see if you have a broken bone.
The time a patient is discharged from the hospital.
The dollar amount removed from your bill, usually because of a contract between your provider and your insurance company.
The exact date a patient was born.
Occurs when an insurance company finds there is insufficient evidence on a claim to prove that a provider performed coded medical services and so they reduce or remove those codes.
Drugs that do not require administration from doctors or nurses. Your insurance plan may not cover these when provided as part of an outpatient service.
The amount your insurance company has agreed to pay.
The amount you owe.
A formal request typically submitted by an insurance carrier to determine if other health coverage exists for a patient.
The medical equipment that can be used many times, or special equipment ordered by your doctor, usually for use at home.
The date on which a Benefit Contract for coverage begins.
Equipment or medical procedure that measures electricity in the brain.
Equipment or medical procedure that measures how your heart works, and your doctor’s reading of the results.
Medical procedures, treatments or interventions that are planned in advance and are considered nonemergent or nonurgent care. With few exceptions, cosmetic procedures are elective services.
A claim sent electronically to an insurance carrier from a provider’s billing software. The format of electronic claims must adhere to medical billing regulations set forth by the federal government.
A method of transferring money electronically from a patient’s bank account to a provider or an insurance carrier.
A digitized medical record for a patient managed by a provider onsite. EMRs may also be referred to as electronic health records (EHRs).
The digital version of the Explanation of Benefits (EOB), which specifies the details of payments made on a claim either by an insurance company or required by the patient.
A determination of whether or not a person meets the requirements to participate in the plan.
The maximum dollar amount allowed for covered services rendered by participating providers and facilities. Deductibles and coinsurance amounts are calculated from eligible charges.
The medical services covered by an insurance company.
Care provided in a hospital Emergency Department.
The part of a hospital that treats patients with emergency or urgent medical problems.
An illness, injury, symptom (including severe pain), or condition severe enough to risk serious danger to your health if you did not get medical attention right away.
Ambulance services for an emergency medical condition, which may include transportation by air, land, or sea.
Services to check for an emergency medical condition and treat you to keep it from getting worse. These services may be provided in a licensed hospital’s emergency room or other place that provides care for emergency medical conditions.
Typically, an unplanned visit requiring care in the emergency department that may extend to an inpatient stay.
A person who is covered by health insurance.
The Employee Retirement Income Security Act of 1974, which established guidelines and requirements for health and life insurance policies including appeals and disclosure of grievances.
The amount the provider estimates you or your insurance company owes.
An estimate of payments from your insurance company.
Refers to the section of CPT codes most used by healthcare personnel to describe a patient’s medical needs.
A written guide from your health plan that explains what the plan does and does not cover and the rules you must follow for getting care.
Health care services that your plan does not pay for or cover.
These health insurance plans do not require patients to choose a primary care physician or obtain a referral to see a specialist but often have a limited network of providers.
A drug, device, diagnostic procedure, treatment, preventive measure or similar medical intervention that is not yet proven to be medically safe and/or effective. Services considered to be investigational are typically not covered by health insurance.
A statement sent to you by your insurance after they process a claim sent to them by a provider. The EOB lists the amount billed, the allowed amount, the amount paid to the provider and any co-payment, deductibles or coinsurance due from you.
A code describing a place or item that may have caused injuries, poisoning, or health problems.
A number assigned by the federal government to doctors and hospitals for tax purposes.
A type of health insurance wherein the provider is paid for every service they perform. People with fee-for-service plans typically can choose whatever hospitals and physicians they want in exchange for higher deductibles and co-pays.
A predetermined list of charges or fees established by a healthcare provider, facility or insurance company for specific medical services, procedures or treatments.
Adjustments made for qualified responsible parties, based on financial assistance applications and established financial guidelines.
Free or reduced rates for care provided to patients with demonstrated financial hardship.
The amount of your bill you have to pay.
A Medicare agent that processes Medicare claims.
An employee benefit that allows a fixed amount of pre-tax wages to be set aside for qualified expenses, including out-of-pocket medical expenses. Employees lose any unused dollars in the account at the end of the year.
A list of preferred prescription medicines. The formulary sorts drugs into groups, or tiers, based on how much of the costs your health plan will pay and how much you have to pay.
Fraud: purposely billing for services that were never given or billing for a service at a higher reimbursement than the service produced. Abuse: payment for items or services billed by mistake that should not be paid for by the insurance plan.
Drugs with proven benefits that cost less because they are not made by major drug companies and do not carry brand names.
Programs that offer financial assistance to help patients pay for out-of-pocket expenses toward their specific disease, including copay, coinsurance, deductible, insurance premiums, and sometimes lodging and travel.
A complaint that you communicate to your health insurer or plan.
The charge for an individual item or service reflected on a hospital’s charge master. These full charges are related to the underlying cost of the service; however, they rarely represent the amount you or your health plan will pay when you have insurance coverage.
A plan provided by an employer to provide healthcare options to a large group of employees.
The name of the group, insurance carrier, or insurance plan that covers a patient.
A number given to a patient by their insurance carrier that identifies the group or plan under which they are covered.
The person responsible to pay the bill. The guarantor is always the patient unless the patient is an incapacitated adult or an unemancipated minor, in which case, the guarantor is the patient’s parent or legal guardian.
Health care services that help a person keep, learn or improve skills and functioning for daily living, such as physical and occupational therapy and speech-language pathology.
Ohio’s version of the federally required disproportionate share hospital program, which provides additional payments to hospitals that provide a disproportionate share of uncompensated services to the indigent and uninsured.
The officially recognized standard document utilized by physicians and other healthcare professionals for submitting invoices and claims to request reimbursement for outpatient services from Medicare, Medicaid and private insurance companies.
The party that provides medical services, such as hospitals, doctors or laboratories.
A three-tier coding system used to explain services, devices, and diagnoses administered in the healthcare system.
A five-digit numbering system that helps standardize professional and outpatient facility billing.
The officially recognized standard document utilized by physicians and other healthcare professionals for submitting invoices and claims to request reimbursement for outpatient services from Medicare, Medicaid and private insurance companies.
Ohio’s version of the federally required disproportionate share hospital program, which provides additional payments to hospitals that provide a disproportionate share of uncompensated services to the indigent and uninsured.
Ohio’s version of the federally required disproportionate share hospital program, which provides additional payments to hospitals that provide a disproportionate share of uncompensated services to the indigent and uninsured.
The officially recognized standard document utilized by physicians and other healthcare professionals for submitting invoices and claims to request reimbursement for outpatient services from Medicare, Medicaid and private insurance companies.
A five-digit numbering system that helps standardize professional and outpatient facility billing.
A three-tier coding system used to explain services, devices, and diagnoses administered in the healthcare system.
The party that provides medical services, such as hospitals, doctors or laboratories.
The major healthcare legislation passed in 2010 designed to make healthcare accessible and less expensive for more Americans.
A contract that requires a health insurer to pay some or all of your health care costs in exchange for a premium. Also called a policy or plan.
The unique number ascribed to an individual to identify them as a beneficiary of Medicare.
These health insurance plans require patients to choose a primary care physician for referrals for specialized care that are in network. HMO plans usually only pay for providers that are in network.
A health plan refers to the type of health insurance you have, which may be a group plan through your employer, an individual plan, workers’ compensation, or a government plan such as Medicare and Medicaid.
An account associated with a high-deductible health plan that allows you to set aside pretax dollars to pay your deductible or other qualified medical expenses. Funds roll over year after year if not spent.
A high deductible health plan with a health savings account (HSA) provides medical coverage and a tax-free way to save for future medical expenses.
The federal Health Insurance Portability and Accountability Act sets standards for protecting the privacy of your health information.
An agency that treats patients in their homes.
Health care services and supplies you get in your home under your doctor’s orders. Services may be provided by nurses, therapists, social workers, or other licensed health care providers.
The group that offers inpatient, outpatient and home healthcare for terminally ill patients.
This refers to the charges for services rendered in a hospital outpatient clinic or department.
The amount of money the hospital charges for a particular medical service or supply.
A federal system that pays a fixed fee for inpatient care.
Care in a hospital that requires admission as an inpatient and usually requires an overnight stay.
Care in a hospital that usually does not require an overnight stay.
An international set of codes that represent diagnoses of patients’ medical conditions as determined by physicians, used in medical billing.
The updated international set of codes based on the preceding ICD-9 codes, used to represent diagnoses and procedures in medical billing.
The charges for nursing services added to basic room and board charges.
A type of health insurance plan whereby a patient can receive care with any provider in exchange for higher deductibles and co-pays. Also known as fee-for-service insurance.
Health insurance purchased by an individual, not as part of a group plan.
Sometimes called the individual mandate, the duty you may have to be enrolled in health coverage that provides minimum essential coverage.
The patient is seeking services through their insurer’s designated preferred provider. The patient/guarantor will receive maximum benefits if care is received from an in network provider.
Your share (for example, 20%) of the allowed amount for covered health care services. Your share is usually lower for in-network covered services.
A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network copayments are usually less than out-of-network copayments.
A provider who has a contract with your health insurer or plan to provide services to you. Also known as a preferred provider.
Patients who stay overnight in the hospital.
Name of the company that your claim will be sent to.
The services excluded from your insurance policy, such as cancer care or obstetric/gynecologic or pre-existing conditions.
The name of the group or insurance plan that insures you, usually an employer.
A number that your insurance company uses to identify the group under which you are insured.
The name of the insured person, who is also referred to as the member.
The medical or surgical care unit in a hospital that provides care for patients who need more care than a general medical or surgical unit can provide.
A number assigned to your bill by your insurance company or their agent.
The official system of assigning codes to diagnoses and procedures associated with hospital utilization in the United States.
A professional organization of physicians who have a contract with an HMO.
An itemized list of services provided. The itemized statement includes the CPT and diagnosis codes used when submitting a claim to an insurance plan. An itemized statement is not a bill.
Treatment provided by giving intravenous solutions or drugs.
A unit of a hospital where babies are born.
Charges for blood tests and tests on body tissue samples, such as biopsies.
The person or persons liable or under obligation for the bill.
The Affordable Care Act prohibits health plans from putting annual or lifetime dollar limits on most benefits you receive.
Under Medicare, you have a lifetime reserve of 60 more days of inpatient services after you use the first 90 benefit days. You must pay a fixed amount for each day of service.
The care received in a nursing home.
A digital representation of data or information in a file that can be imported or read into a computer system for further processing. Examples include .XML, .JSON and .CSV formats.
A type of insurance plan that requires patients to only see providers that have a contract with the managed care company, except in the case of medical emergencies or urgent care.
A system of healthcare delivery that tries to manage the costs and quality of healthcare and access to care. It often involves use of contracted provider networks and care authorization systems.
A marketplace for health insurance where individuals, families and small businesses can learn about their plan options, compare plans, apply for financial help, and enroll in coverage. Also known as an Exchange.
The yearly amount the federal government sets as the most each individual or family can be required to pay in cost sharing during the plan year for covered, in-network services.
Medicaid is a jointly funded federal and state health insurance plan administered by states for low income adults, pregnant women, children and people with certain disabilities.
An employee in the healthcare system such as a physician’s assistant or a nurse practitioner who performs duties in administration, nursing, and other ancillary care.
A professional responsible for using information regarding services and treatments performed by a healthcare provider to complete a claim for filing with an insurance company.
A professional responsible for assigning various medical codes to services and healthcare plans described by a physician on a patient’s superbill.
Health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms. Does not include cosmetic or investigative services.
The number assigned by your doctor or hospital that identifies your individual medical record.
An optional health insurance payments plan whereby a person apportions part of their untaxed earnings to an account reserved for healthcare expenses. Unused funds roll over to the next year.
The process of converting dictated or handwritten instructions, observations, and documentation into digital text formats.
Special supplies, such as materials used to repair a wound or instruments used for your care.
Health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms, including habilitation, and that meet accepted standards of medicine.
Medicare is a federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with end-stage renal disease.
A Medicare HMO insurance plan that pays for preventive and other types of healthcare provided by designated doctors and hospitals.
Organizations that contract with the federal government to process Medicare claims.
A type of Medicare health plan offered by an insurance company that contracts with Medicare to provide all Part A and Part B benefits, plus additional benefits.
Medical services for which Medicare normally pays.
Providers who have accepted Medicare patients and agreed not to charge them more than Medicare has approved.
Referring to the 61st through 90th days of inpatient treatment, the law requires that patients pay for a portion of their healthcare during these days.
The discrepancy between the limits of healthcare insurance coverage and the Medicare Part D coverage limits for prescription drugs.
Providers that do not accept assignment are called nonparticipating providers and have not signed an agreement to accept assignment for all Medicare-covered services.
A Medicare card with a unique number is assigned to each person covered under Medicare, used by providers for billing, eligibility and claim status.
The amount of your bill that Medicare paid.
The amount of your bill that Medicare paid to your doctor or hospital.
Usually referred to as Hospital Insurance, it helps pay for inpatient care in hospitals and hospices, as well as some skilled nursing costs.
Assists with paying for doctor services, outpatient care and other medical services not paid for by Medicare Part A.
A federally mandated program that asks Medicare patients questions to determine whether Medicare is the primary or secondary payer prior to each visit.
Effective April 1, 2013, Medicare claims incur a 2% reduction in Medicare payment. The adjustment is applied to all claims after determining coinsurance, applicable deductibles and secondary payment adjustments.
A statement that Medicare sends to you after they process a claim from a provider for services provided to you, listing the amount billed, the allowed amount, the amount paid, and any amounts due from you.
Policies that supplement Medicare coverage. Most times, these policies pay the Medicare co-pays and deductibles.
Health coverage that will meet the individual responsibility requirement, generally including plans available through the Marketplace, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage.
A basic standard to measure the percent of permitted costs a plan covers. A plan offers minimum value if it pays for at least 60% of the total allowed costs of benefits.
Additions to CPT codes that explain alterations and modifications to an otherwise routine treatment, exam, or service.
A type of X-ray using magnetic resonance to produce brain or body images, usually done in a hospital’s X-ray department.
A unique 10-digit number ascribed to every healthcare provider in the U.S. as mandated by HIPAA.
A group of doctors, hospitals, pharmacies and other healthcare experts hired by a health plan to take care of its members.
A provider who has a contract with your health insurer or plan and has agreed to provide services to members of a plan at a negotiated rate.
The charges for medical services denied or excluded by your insurance. You may be billed for these charges.
Typically a planned visit or service.
Services not covered under the limits of the patient’s health insurance contract. These amounts are the patient’s responsibility to pay.
A doctor, hospital or other healthcare provider that is not part of an insurance plan, doctor or hospital network.
The choice by a healthcare provider not to participate in a particular health insurance plan or network.
A term used to describe a procedure or service that cannot be described within the available code set.
A term used in ICD-9 codes to describe conditions with unspecified diagnoses.
Nursing care charges for born babies.
A hospital outpatient service ordered by a physician when the physician is not yet sure that you will need inpatient hospital care, but feels you need outpatient monitoring at the hospital in the meantime.
The organization responsible for establishing guidelines and investigating fraud and misinformation within the healthcare industry, part of the Department of Health and Human Services.
Charges for treating cancer and related diseases.
The period each year during which you can join a plan or change plans if your employer offers more than one plan.
A hospital or clinic area where surgeries are performed.
Leg, arm, back and neck braces, artificial legs, arms, and eyes, and external breast prostheses after a mastectomy, including adjustment, repairs, and replacements.
Any extra charges that cannot be included in routine room and board charges.
The patient is seeking services through a non-preferred provider. Depending on the insurance plan, benefits may be reduced or not covered at all.
Your share (for example, 40%) of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan.
A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan.
A doctor or other healthcare provider who is not part of an insurance plan, doctor or hospital network.
The costs the patient is responsible for because Medicare or other insurance does not cover them.
The most money you will have to pay before your insurance company covers all costs. Once that limit is reached, the plan will pay 100% of the allowed amount for eligible charges for the rest of the calendar year.
The most you could pay during a coverage period (usually one year) for your share of the costs of covered services. After you meet this limit, the plan will usually pay 100% of the allowed amount.
A service you receive in one day at a hospital or clinic without staying overnight.
Drugs that do not require a prescription. They can be bought at a pharmacy or drugstore.
The amount the insurance company pays to your medical provider.
The amount the insurance company pays to you or your guarantor.
A doctor or hospital that agrees to accept payment from your insurance (for covered services) as payment in full, minus your deductibles, copays and co-insurance amounts.
The amount your provider charges you for services received.
The amount a patient owes a provider after an insurance company pays for their portion of the medical expenses.
A way to classify patients — outpatient, inpatient, etc.
The amount you owe toward your medical bill.
A third-party entity (commercial or government) that pays medical claims.
The charge or allowable amount that the hospital has negotiated with your health plan for an item or service. You and your health plan will not pay more than this amount.
A formal payment plan set up with a Financial Counselor or Patient Financial Services when the balance due cannot be entirely paid by the due date.
Hospital receives payment for each day a service is provided to the patient.
An institution such as a hospital receives a set rate of compensation per day, rather than reimbursement for charges for each service provided.
Hospital receives a payment that is a portion of the cost of services provided to the patient, represented as a percentage of the total cost billed.
Third-party administrators of prescription drug programs used by commercial health plans, self-insured employer plans, Medicare Part D plans, and others.
Cost of drugs given under a pharmacist’s direction.
Treatment of diseases or injuries by exercise, heat, light, and/or massage.
A person licensed to practice medicine.
Also called mid-level service providers, physician extenders include licensed nurse practitioners and/or licensed physician assistants who coordinate patient care under a doctor’s supervision.
Your doctor’s office.
A method by which a physician agrees to accept an insurance company’s payment level as payment in full, with the bill sent directly to the insurance company.
A group of doctors, nurses and physician assistants who work together.
Non-physician staff hired to manage the business aspect of a physician practice, including billing, medical records, reception, lab and X-ray technicians, human resources, and accounting.
Health care services a licensed medical physician provides or coordinates.
A two-digit code used on claims to explain what type of provider performed healthcare services on a patient.
Health coverage issued to you directly or through an employer, union, or other group sponsor that provides coverage for certain health care costs.
These health insurance plans resemble HMOs but are less restrictive because patients can get coverage for out-of-network care in certain defined circumstances.
A number your insurance company gives you to identify your contract.
A legal document that allows you to appoint another person to act on your behalf and make certain decisions for you, including healthcare decisions.
Software used for scheduling, billing, and recordkeeping at a provider’s office.
An agreement made by your insurance company and you or your provider, to pay their portion of your medical treatment. Providers ask your insurance company for this approval before providing your medical treatment.
Permission from your medical group or health plan to get a service that requires a referral from your doctor. Also called authorization or prior authorization.
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification.
The process of obtaining authorization from the health plan for routine hospital admissions and surgical encounters. Failure to obtain pre-certification often results in reduced reimbursement or denial of claims.
A maximum sum as explained in a healthcare plan that an insurance company will pay for certain services or treatments.
A medical condition for which the patient has received treatment during a specific period of time prior to enrolling in an insurance plan. Under the Affordable Care Act, pre-existing condition exclusions are no longer allowed.
The existence of a pre-existing condition that denies a person certain coverage in some health insurance plans.
These health insurance plans maintain a network of providers but may cover out-of-network care, typically with a higher cost to the patient.
The amount that must be paid for your health insurance or plan, usually paid monthly, quarterly, or yearly.
Financial help that lowers your taxes to help you and your family pay for private health insurance obtained through the Marketplace.
The money you pay before receiving medical care; also referred to as preadmission deposits.
When applicable, a dollar amount predetermined by the provider to be paid before your visit.
Coverage under a plan that helps pay for prescription drugs, often organized into tiers with different cost-sharing amounts for each tier.
Drugs and medications that by law require a prescription.
A billing charge that is commonly made by doctors in a specific region or community, as determined by your insurance company.
Routine health care, including screenings, check-ups, and patient counseling, to prevent or discover illness, disease, or other health problems.
A group of doctors serving as primary care doctors.
A doctor whose practice is devoted to internal medicine, family and general practice or pediatrics.
A physician, nurse practitioner, clinical nurse specialist, or physician assistant who provides, coordinates, or helps you access a range of health care services.
The insurance primarily responsible for the payment of the claim.
The insurance responsible for paying your claim first, before the secondary insurance pays.
A process used by health insurance plans to determine in advance whether a specific medical treatment, procedure, prescription medication or healthcare service is medically necessary and meets the criteria for coverage.
The insurance responsible for paying your claim first, before the secondary insurance pays.
The insurance primarily responsible for the payment of the claim.
Coverage under a plan that helps pay for prescription drugs, often organized into tiers with different cost-sharing amounts for each tier.
Drugs and medications that by law require a prescription.
A billing charge that is commonly made by doctors in a specific region or community, as determined by your insurance company.
Routine health care, including screenings, check-ups, and patient counseling, to prevent or discover illness, disease, or other health problems.
A group of doctors serving as primary care doctors.
A doctor whose practice is devoted to internal medicine, family and general practice or pediatrics.
A physician, nurse practitioner, clinical nurse specialist, or physician assistant who provides, coordinates, or helps you access a range of health care services.
The insurance primarily responsible for the payment of the claim.
The insurance responsible for paying your claim first, before the secondary insurance pays.
A process used by health insurance plans to determine in advance whether a specific medical treatment, procedure, prescription medication or healthcare service is medically necessary and meets the criteria for coverage.
A number stating that your treatment has been approved by your insurance plan. Also referred to as an Authorization Number, Certification Number or Treatment Authorization Number.
Standards for privacy regarding a patient’s medical history and all related events, treatments, and data as outlined by HIPAA.
A more expensive hospital room than those available to other patients. You may have to pay extra for this type of room if it is not a medical necessity.
A code given to medical and surgical procedures and treatments.
Documentation or evidence that an individual has an active health insurance policy in place, including the policyholder’s name, insurance company details, policy number, and coverage information.
A method of reimbursement in which Medicare payment is made based on a predetermined fixed amount.
A hospital or physician who provides medical care to the patient.
A part of your bill that your provider must write off because of billing agreements with your insurance company.
A provider’s current legacy provider number with Medicare.
Nursing care and other services for emotionally disturbed patients, including patients admitted for inpatient care and those admitted for outpatient treatment.
X-rays used to identify and diagnose medical problems.
Also called allowable or allowed amount, this refers to the maximum amount that an insurance company is willing to pay for covered medical services or procedures.
Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries, or medical conditions.
A special room where you are taken after surgery to recover before being sent home or to your hospital room.
Approval needed for care beyond that provided by your primary care doctor or hospital. For example, managed care plans usually require a referral from your primary care doctor to see a specialist.
The process by which individuals officially enroll or register with a healthcare professional or system to receive medical services.
Health care services that help a person keep, get back, or improve skills and functioning for daily living. May include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation.
A signed statement from patients or guarantors that allows providers to release medical information so that insurance companies can pay claims.
The median amount Medicare will repay a provider for certain services and treatments.
The explanation the hospital receives, usually with payment, from your insurance company after your medical services have been processed.
Removal of wastes from the blood, normally performed by the kidneys. Used when the kidneys are not functioning properly.
Giving oxygen and drugs through breathing, as well as other therapies that measure inhaled and exhaled gases and blood samples.
The person responsible for paying your hospital bill, usually referred to as the guarantor.
A billing code used to name a specific room, service or billing sum.
Routine charges for a room with one bed.
Routine charges for a room with two beds.
A surgery performed as an outpatient service.
A type of preventive care that includes tests or exams to detect the presence of something, usually performed when you have no symptoms, signs, or prevailing medical history of a disease or condition.
A process by which insurance claims are checked for errors before being sent to an insurance company for final processing.
For people who are covered by more than one insurance plan, the secondary policy may cover expenses after the primary insurance has paid its part of the healthcare bill.
The claim filed with the secondary insurance company after the primary insurance company pays for their portion of healthcare costs.
The insurance company responsible for processing the claim after the primary insurance determines what it will pay.
When the provider performs another procedure on a patient covered by a CPT code after first performing a different CPT procedure on them.
The guidelines for policies and practices necessary to reduce security risks within the healthcare system, working in concert with HIPAA security guidelines.
A group health plan in which the employer assumes the risk for providing healthcare benefits to their employees.
A person who pays out-of-pocket for healthcare services in absence of insurance.
A patient who has no insurance or does not want the services rendered to be filed with his or her insurance company.
When a patient does their own research to find a provider and acts outside of their primary care physician’s referral.
A geographic area where insurance plans enroll members. In an HMO, it is also the area served by your doctor network and hospitals.
The date your medical services or treatments began.
A code describing medical services you received.
The date your medical services or treatments ended.
A patient’s official signature on file for the purpose of billing and claims processing.
A reimbursement agreement between a provider and a patient’s health insurer/payer related to a single patient and limited to a single encounter, episode, or specified period of time.
Services performed or supervised by licensed nurses in your home or in a nursing home. Skilled nursing care is not the same as skilled care services performed by therapists or technicians.
An inpatient facility in which patients who do not require acute hospital care are provided with nursing care or other therapy.
An income assistance program administered by the federal government for those with disabilities.
A disability income program through SSA for disabled people who have not worked enough to pay much into the Social Security System.
Medical billing software hosted offsite by another company and only accessible with Internet access. Useful for providers who do not want to maintain and update in-house medical billing software.
The source of your admission, whether it is a referral, transfer or through the emergency room.
A doctor who specializes in treating certain parts of the body or specific medical conditions.
A type of prescription drug that generally requires special handling or ongoing monitoring and assessment by a health care professional, or is relatively difficult to dispense. Generally, the most expensive drugs on a formulary.
Defined by CMS as the information to be included within the machine-readable file: gross charge, cash charge, payer-specific negotiated rate, de-identified payer-specific negotiated rate, and de-identified maximum negotiated rate.
A printed summary of your medical bill.
The dates your service or treatment begin and end.
The identification number (ID) doctors and hospitals use when they bill electronically.
The individual covered under a group policy, or the person who holds and/or is responsible for the medical insurance policy.
A document used by healthcare staff and physicians to record information about a patient receiving care, including demographic and insurance information and any diagnoses or healthcare plans written by the physician.
Any private health insurance plan held by a Medicare or commercial beneficiary that helps cover out-of-pocket expenses, copayments, deductibles and other costs not fully covered by the primary plan.
An additional insurance policy that handles claims for deductible and co-insurance reimbursement.
A bed for a patient who receives skilled nursing care in a non-skilled nursing facility.
A unique number a patient or company may have to produce for billing purposes. Also known as the Employment Identification Number (EIN).
A unique codeset used by medical billing specialists for identifying a healthcare provider’s specialty field.
The end date for an insurance policy contract, or the date after which a person no longer receives or is no longer eligible for health insurance.
A claim filed by a provider after they have filed claims for primary and secondary health insurance coverage. Tertiary insurance claims often cover remaining healthcare costs such as deductibles and co-pays.
Third-party administrators handle the administrative duties and sometimes utilization review for self-funded plans.
An organization other than the patient (first party) or healthcare provider (second party) involved in paying healthcare claims.
With a tiered network product, the member’s benefit level of cost sharing is determined by the network of the independently contracted provider that renders the service.
Total cost of your medical services.
A number stating that your treatment has been approved by your insurance plan. Also referred to as an Authorization Number, Certification Number or Prior Authorization Number.
A unique number the insurance company gives the provider for billing purposes. A provider must receive the TAR number before administering healthcare to a patient covered by the company.
Tricare is a health care program for active duty and retired uniformed service members and their families.
Also referred to as the cafeteria plan, this plan gives an enrolled individual the option to choose between an HMO, a PPO, or a traditional point of service plan for their health insurance.
The reason for your admission, such as emergency, urgent or elective, etc.
A bill that shows what type of care is being billed, such as hospital inpatient, hospital outpatient, skilled nursing care, etc.
A field on a claim for describing what kind of healthcare services or procedures a provider administered.
The standard claim form used by institutional providers, like hospitals, to bill insurance companies for medical services.
The fraudulent practice of ascribing more than one code to a service or procedure on a claim form when only one is necessary.
A patient without public or private health insurance.
A unique six-digit identification number previously given to physicians and other healthcare personnel, subsequently replaced by a National Provider Identifier (NPI) number.
Measures of medical services a patient received, such as the number of hospital days, pints of blood, treatments or laboratory tests.
When a provider fails to file a claim with an insurance company within the required timeframe, it is marked for untimely submission and will be denied.
The fraudulent practice of ascribing a higher ICD-10 or CPT code to a healthcare procedure to receive more money than necessary from the insurance company or patient.
Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.
In general terms, the price charged by the provider for a service, considered usual and customary if it falls within the range of prices charged for the same service by other providers in the same geographical area.
Medicare sets limits on how many times some services can be provided in a year. If services exceed this utilization limit, your claim could be denied.
A process of tracking, reviewing and rendering opinions about care. The practices of pre-certification, recertification, retrospective review and concurrent review all describe utilization review methods.
A codeset under ICD-9-CM used to organize healthcare services rendered for reasons other than illness or injury.
A number assigned to identify each episode of care, used to track services and payments. Also referred to as account number.
The amount of time members must wait after enrolling in an insurance plan before they are eligible for certain benefits.
Insurance that employers are required to have to cover medical care of employees who incur an injury or illness on the job.
The discrepancy between a provider’s fee for healthcare services and the amount that an insurance company is willing to pay for those services that a patient is not responsible for.
The amount you must pay each year before your health plan starts to pay. Also called annual deductible.
The most you have to pay for most health care services in a year. In some cases, you may still have to pay copays for some services.
A phrase used by your insurance company informing you that your doctor or hospital may bill some charges directly to you.
A codeset under ICD-10-CM used to organize healthcare services rendered for reasons other than illness or injury.
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