A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Account
The number a patient is given by the doctor or hospital for a medical visit.

Accounts receivable
The total amount of money owed for professional services provided.

Adjudication
The final determination of the issues involving settlement of an insurance claim, also known as a claim settlement.

Adjustment
The portion of the bill that the doctor or hospital has agreed not to charge you.

Advance Beneficiary Notice (ABN)
An agreement given to the patient to read and sign before providing a service if the participating physician thinks that it may be denied for payment because of medical necessity or limitation of liability by Medicare. Once a patient signs the ABN and if Medicare does not pay for it, then the patient will have to pay the physician for it. The patient agrees to pay for the service; also known as a waiver of liability agreement or responsibility statement.

Appeal
To request correct payment by asking for a review of an insurance claim that has been paid or denied by an insurance company.

Applicant
Person applying for insurance coverage.

Approved Amount
The fee Medicare sets as reasonable for a covered medical service. This is the amount a doctor or supplier is paid by you and Medicare for a service or supply. It may be less than the actual amount charged by a doctor or supplier. The approved amount is sometimes called the "Approved Charge."

Beneficiary
Person covered by health insurance or Medicare benefits.

Benefit
The amount your insurance company pays for medical services.

Benefit period
A benefit period begins the day you go to a hospital or skilled nursing facility. The benefit period ends when you haven't received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

Blue Cross and Blue Shield Association (BSBSA)
An association that represents the common interests of Blue Cross and Blue Shield health plans. The BCBSA serves as the administrator for the Health Care Code Maintenance Committee and also helps maintain the HCPCS Level II codes.

Capitation
A fixed amount of money, per capita amount for each patient enrolled over a stated period of time, paid to a health plan or doctor (regardless of the type and number of services provided). This is used to cover the cost of a health plan member's health care services for a certain length of time.

Centers for Medicare and Medicaid Services (CMS)
Formerly known as the Health Care Financing Administration (HCFA). CMS is responsible for oversight of HIPAA administrative simplification transaction and code sets, health identifiers, and security standards. CMS also maintains the HCPCS medical code set and the Medicare Remittance Advice Remark Codes administrative code set.

Claim Control Number
A number assigned by the Medi-Cal fiscal intermediary on a Treatment Authorization Request and used for reference when processing the request.

Claims Inquiry Form (CIF)
A Medi-Cal form used for tracing a claim, resubmitting a claim after a denial, or when requesting an adjustment for underpaid or overpaid claims.

Clean Claim
A completed insurance claim form submitted within the program time limit that contains all the necessary information without deficiencies so it can be processed and paid promptly.

Clearinghouse
A company that, for a fee, electronically receives batches of claims from providers or billing centers in a single format, reformats the claims data according to the software requirements of the indicated insurance carriers or governmental agencies, and retransmits the data electronically to those designated payers. There is a contractual financial relationship between the clearinghouse and the payer. The electronic claims are edited upon arrival at the clearinghouse terminal. A report is issued describing on the requirements of the ultimate payer.

Coding
A system whereby a numerical code is applied to medical descriptions of diagnoses, procedures, pharmaceutical elements, and durable medical equipment. These numerical descriptions permit easy accounting procedures for statistical classification.

Coinsurance
A fixed percentage of the total amount paid for a health care service that can be charged to a beneficiary on a per service basis.

Collection ratio
The relationship between the amount of money owed and the amount the money collected in reference to the doctor’s accounts receivable.

Contractual Adjustment
A part of the bill that the doctor or hospital must write off (not charge the patient) because of billing agreements with his/her insurance company.

Coordination of Benefits (COB)
A process that determines which plan or insurance policy will pay first if two health plans or insurance policies cover the same benefits. If one of the plans is a Medicare health plan, Federal law may decide who pays first.

Copayment
A copayment is usually a specified flat amount you pay for a service (e.g., $10 per visit, $25 per inpatient hospital day), with the insurer paying the balance. Also referred to as coinsurance.

CPT codes
A coding system used to describe what treatment or services were given to the patient by the doctor.

Crossover claim
Bill for services rendered to a patient receiving benefits simultaneously from Medicare and Medicaid.

Current Procedural Terminology (CPT)
A reference procedural codebook using a numerical system for procedures, established by the American Medical Association.

Date of Service (DOS)
The date(s) when a patient was treated.

Day Sheet
A register for recording daily business transactions (charges, payments, or adjustments); also known as daybook, daily log, or daily record sheet.

Deductible
Specific dollar amount that must be paid by the insured before a medical insurance plan or government program begins covering health care costs.

Defense Enrollment Eligibility Reporting System (DEERS)
An electronic database used to verify beneficiary eligibility for those individuals in the TRICARE programs.

Denied claim
Insurance claims submitted to an insurance company in which payment has been rejected due to technical error or because of medical coverage policy issues.

Diagnosis Code
A code used for billing that describes the illness.

Diagnosis-Related Groups (DRGS)
A classification system that groups patients according to diagnosis, type of treatment, age, and other relevant criteria. Under the prospective payment system, hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost of care for the individual.

Direct Referral
Certain services in a managed care plan may not require preauthorization. The authorization request form is completed and signed by the physician and handed to the patient to be done directly.

Dirty Claim
A claim submitted with errors or one that requires manual processing to resolve problems or is rejected for payment.

Downcoding
Reduce the value and code of a claim when the documentation does not support the level of service billed by a provider. The insurance company computer system converts the code submitted to the closest code in use, which is usually down one level from the submitted code, generating decreased payment.

E codes
A classification of ICD-9-CM coding used to describe environmental events, circumstances, and conditions as the external cause of injury, poisoning, and other adverse effects. E codes are also used in coding adverse reactions to medications.

Electronic Claim
Insurance claim submitted to the insurance carrier via a central processing unit (CPU), tape diskette, direct date entry, direct wire, dial-in-telephone, digital fax, or personal computer download or upload.

Electronic Claims Professional (ECP)
Individual who converts insurance claims to standardized electronic format and transmits electronic insurance claims date to the insurance carrier or clearinghouse to help the physician receive payment.

Electronic Funds Transfer
A paperless computerized system enabling funds to be debited, credited, or transferred, eliminating the need fore personal handling of checks.

Employer Identification number (EI)
An individual’s federal tax identification number issued by the Internal Revenue Service for income tax purposes.

Explanation of Benefits (EOB)
An explanation of services periodically issued to recipients or providers on whose behalf claims have been paid. It tells what was billed, the payment amount approved by the insurance, the amount paid, and what the patient has to pay. It also gives the reasons for denying a claim.

Explanation of Medical Benefits (EOMB)
An explanation of Part B services under the Original Medicare Plan sent to patients and/or physicians on whose behalf claims have been paid. This notice explains what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay.

Fiscal Intermediary
A private company that has a contract with Medicare to pay Part A and some Part B bills. For TRICARE and CHAMPVA, the insurance company that handles the claims for care received within a particular state or country.

Group provider number
A number assigned to a group of physicians submitting insurance claims under the group name and reporting income under one name; used instead of the individual’s physician’s number for the performing provider.

Guarantor
Someone other than the patient who has agreed to pay the bill on the patient’s behalf.

Health Care Financing Administration (HCFA), now changed to CMS
Formerly known as the Social Security Administration, HCFA is that part of the Department of Health and Human Services that oversees Medicare, among other governmental health programs. Health Insurance – known at Medicare part A. A program providing basic protection against the costs of hospital and related post hospital services for individuals eligible under the Medicare program. Pronounced “Hick-fa”.

Health Maintenance Organization
An insurance plan that pays for preventative and other medical services provided by a specific group of participating providers.

Health Maintenance Organization (HMO)
A type of health care program in which enrollees receive benefits when they obtain services that are provided or authorized by selected providers, usually with a primary care physician “gatekeeper.” In general, enrollees do not receive coverage for the services of providers who are not in the HMO network, except for emergency services.

Healthcare Common Procedure Coding System (HCPCS)
A medical code set, which has been selected for use in the HIPAA transactions, identifies health care procedures, equipment, and supplies for claim submission purposes. HCPCS Level I contains numeric CPT codes which are maintained by the AMA. HCPCS Level II contains alphanumeric codes used to identify various items and services that are not included in the CPT medical code set. These are maintained by HCFA, the BCBSA, and the HIAA. HCPCS Level III contains alphanumeric codes that are assigned by Medicaid state agencies to identify additional items and services not included in levels I or II. These are usually called "local codes", and must have "W", "X", "Y", or "Z" in the first position. HCPCS Procedure Modifier Codes can be used with all three levels, with the WA - ZY range used for locally assigned procedure modifiers.

HIPAA
Health Insurance Portability and Accountability Act. This federal act sets standards for protecting the privacy of your health information.

Inpatient
A term used when a patient is admitted to the hospital for overnight stay.

Insurance balance billing
A statement sent to the patient after his or her insurance company has paid its portion of the claim.

Insurance Billing Specialist
A practitioner who carries out claims completion, coding, and billing responsibilities and may or may not perform managerial and supervisory functions; also known as an insurance claims processor or reimbursement specialist.

Major Diagnostic Categories (MDCs)
A broad classification of diagnoses. There are 83 coding system-oriented MDCs in the original DRGs and 23 body system-oriented MDCs in the revised set of DRGs.

Managed Care Organizations (MCOs)
Entities that serve Medicare or Medicaid beneficiaries on a risk basis through a network of employed or affiliated providers. May apply to EPO, HMO, PPO, integrated delivery system, or other weird arrangement, MCOs are usually prepaid group plans, and physicians are typically paid by the capitation method.

Managed Care Plans
An insurance plan that requires patients to see doctors and hospitals that have a contract with the managed care company, except in the case of medical emergencies or urgently needed care if you are out of the plan's service area.

Manual Billing
Processing statements by hand; may involve typing statements or photocopying the patient’s financial accounting record and placing it in a window envelope, which then becomes the statement.

Medicaid (MCD)
A federal aided, state-operated and administered program that provides medical benefits for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid. California’s Medicaid program is known as Medi-Cal.

Medical Record Number
The number assigned by the doctor or hospital that identifies a patient’s individual medical record.

Medicare Assignment
Doctors and hospitals that have accepted Medicare patients and agreed not to charge them more than Medicare has approved.

Medicare Medical Savings Account
A Medicare health plan option made up of two parts. One part is a Medicare MSA Health Policy with a high deductible. The other part is a special savings account, called a Medicare MSA.

Medicare Part A
Usually referred to as Hospital insurance, it helps pay for inpatient care in hospitals and hospices, as well as some skilled nursing costs.

Medicare Part B
Helps pay for doctor services, outpatient care and other medical services not paid for by Medicare Part A.

Medigap
A specialized supplemental insurance policy devised for the Medicare beneficiary that covers the deductible and copayment amounts typically not covered under the main Medicare policy written by a non-governmental third-party payer. Also known as Medifill.

Medigap Policy
A Medicare supplement insurance policy sold by private insurance companies to fill "gaps" in Original Medicare Plan coverage. It may pay deductible, coinsurance amounts, and so forth. It does not include limited benefit coverage, such as “specified disease” or “hospital indemnity” coverage. It excludes a policy or plan offered by an employer or labor organization.

Modifier
In CPT coding, a two-digit add-on or five-digit number, representing the modifier, placed after the usual procedure code number. The two-digit modifier may be separated by a hyphen. In HCPCS coding, one-digit or two-digit add-on alpha characters, placed after the usual HCPCS code number.

National Association of Claims Assistance Professionals
A national professional society for those that submit manual and/or electronic health insurance claims.

NEC
Not Elsewhere Classifiable. This term is used in ICD-9-CM when the coder lacks the information necessary to code the term in a more specific category.

Non-Covered Charges
Charges for medical services denied or excluded by the patient’s insurance. He/she may be billed for these charges.

Non-Participating Provider
A doctor, hospital or other healthcare provider that is not part of an insurance plan's doctor or hospital network.

NOS
Not Otherwise Specified, unspecified. Used in ICD-9-CM.

Old Age survivors, Health and Disability Insurance (OASHDI) Program (C)
A group that in entitled to benefits under the Medi-Cal program.

Original Medicare Plan
The traditional pay-per-visit arrangement that covers Part A and Part B services.

Out-of-Network Provider
A doctor or other healthcare provider who is not part of an insurance plan's doctor or hospital network. Same as non-participating provider.

Outpatient
A patient who receives services in a health care facility, such as a physician’s office, clinic, urgent care center, emergency department, or ambulatory surgical center and goes home the same day.

Participating Provider
A doctor or hospital that agrees to accept a patient’s insurance payment for covered services as payment in full, minus the deductibles, co-pays and coinsurance amounts.

Patient Type
A way to classify patients - outpatient, inpatient, etc.

Point of Service Plan (POS)
An insurance plan that allows a patient to choose doctors and hospitals without having to first get a referral from his/her primary care doctor.

Preauthorization
A requirement of some health insurance plans to obtain permission for a service or procedure before it is done and to see whether the insurance program agrees it is medically necessary.

Precertification
To find out whether treatment (surgery, tests, hospitalization) is covered under a patient’s health insurance policy.

Predetermination
To determine before treatment the maximum dollar amount the insurance company will pay for surgery, consultations, postoperative care, and so forth.

Preferred Provider Organization (PPO)
A type of health benefit program in which enrollees receive the highest level of benefits when they obtain services from a physician, hospital, or to her health provider designated by their program as a “preferred provider”. Enrollees may receive substantial, though reduced, benefits when they obtain care from a provider of their own choosing who is not designated as a “preferred provider” by their program.

Primary Care Physician (PCP)
A physician who is trained to give you basic care. Your primary care doctor is the doctor you see first for most health problems and may talk with other doctors and health care providers about your care and refer you to them. In many Medicare managed care plans, you must see your primary care doctor before you see any other health care provider.

Primary Insurance Company
The insurance company responsible for paying a patient’s claim first. If he/she has another insurance company, it is referred to as the Secondary Insurance Company.

Private Fee-for-Service Plan
A private insurance plan that accepts Medicare beneficiaries.

Procedure Code (CPT)
A code given to medical and surgical procedures and treatments.

Provider
A person, organization, or institution enrolled and certified to provide health care services authorized under Medicaid, Medicare, or managed care programs. For CHAMPUS, the doctor, hospital, or other person or place that provides medical services and/or supplies.

Reauthorization
Requirement in some health insurance plans to obtain permission for service or procedure before it is done and to see whether the insurance program agrees it is medically necessary.

Referral
Permission from your primary care doctor for you to see a specialist or get certain services. In many Medicare managed care plans, you need to get a referral before you get care from anyone except your primary care doctor.

Responsible Party
The person(s) responsible for paying a patient’s hospital bill-usually referred to as the guarantor.

Scrubbing
The process in which computer software checks for errors before a claim is submitted to an insurance carrier for payment; also known as edit check or cleaning the bill.

Secondary Insurance
Extra insurance that may pay some charges not paid by the patient’s primary insurance company. Whether payment is made depends on his/her insurance benefits, the coverage and the benefit coordination.

Secondary Payer (SP)
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.

Skilled Nursing Facility
An inpatient facility in which patients who do not need acute care are given nursing care or other therapy.

Supplemental Insurance Policy
An additional insurance company that handles claims for deductibles and coinsurance reimbursement. Many private insurance companies sell Medicare Supplemental Insurance.

Supplementary Medical Insurance (SMI)
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 Medicare Part B.

UB-92
A uniform Bill insurance claim form developed by the National Uniform Billing Committee for hospital inpatient billing and payment transactions.

UPIN
The Unique Physician identification Number given to each physician providing services paid by Medicare. This six-place Alpha-numeric UPIN is in effect throughout Medicare affiliation in the physician’s current state and any other subsequent states. It is used for assigned or unassigned claims.

Urgently Need Care
Unexpected illness or injury that needs immediate medical attention, but is not life threatening.

Usual, Customary and Reasonable (UCR)
A method used by insurance companies to establish their fee schedules. UCR uses the conversion factor method of establishing maximums; the method of reimbursement used under Medicaid B which state Medicaid programs set reimbursement rates using the Medicare method or a fee schedule, whichever is lower.

Utilization Review (UR)
Hospital staff who work with doctors to determine whether a patient can get care at a lower cost or as an outpatient.

V Codes
A classification of ICD-9-CM coding to identify health care encounters for reasons other than illness or injury and to identify patients whose injury or illness is influenced by special circumstances or problems.