Billing and Insurance Terms
The following list is a compilation of billing, insurance, and commonly used health care terms that will help you understand your bill. If you still have questions about your bill, please call the business office and we will gladly answer them.
Admitting Privileges: The right granted to a doctor, by virtue of membership as a hospital’s medical staff, to admit patients to a particular hospital or medical center.
Adjustment: The portion of your bill that your provider has agreed not to charge you.
Ambulatory Care: The health care that is provided in the doctor’s office and surgical centers without an overnight stay. See: Outpatient Care
Authorization: The approval of care given by an insurer or health plan. Before you are admitted to a medical facility to receive treatment, your insurer or health plan may require pre-authorization. This approval must be received if a patient wants to receive financial assistance from his or her insurance carrier for the price health services incurred.
Beneficiary: A person covered by health insurance
Benefit: The amount your insurance provider pays for medical services.
Capitation: A provider payment method used by health plans. The provider is paid a set amount per member per month. The provider receives the same amount regardless of how many times the member uses his or her services.
Centers for Medicare and Medicaid (CMS): An agency within the US Department of Health & Human Services responsible for administration of Medicare, Medicaid, and other federal health care programs.
Claim: A request sent by a healthcare provider or patient to the patient’s insurance carrier for payment of health services.
Coordination of Benefits (COB): You may have more than one insurance carrier and a COB is an agreement between the different insurers to avoid double payment for your care. The agreement decides which insurer will take primary and secondary responsibility.
Co-Insurance: A type of cost sharing between the patient and his or her insurance carrier after a deductible is paid. For instance, the insurance carrier will agree to pay 80% of the remaining
Co-Payment: Copayment is the portion of a claim or medical expense that you must pay out-of-pocket. Copayment usually is a minimal fixed amount.
Deductible: A fixed portion of your healthcare bill that you are required to pay before your insurance will pay. After you pay your deductible your insurance carrier will help pay your medical bill, but you may still have a co-insurance cost sharing agreement in your health benefit plan.
Department of Health and Human Services (DHHS): DHHS administers many of the “social” programs at the Federal level dealing with the health and welfare of the citizens of the United States. It is the “parent” of CMS.
Diagnosis Code: A code used at the time of billing to describe your illness.
Explanation of Benefits (EOB): The notice sent to covered persons after a bill is processed or paid. The notice tells the amount the provider billed, the amount paid by the insurance, and what the patient now has to pay.
Gatekeeper: A primary care doctor within a Managed Health Organization (HMO). This doctor gives you basic medical services and coordinates proper medical care and is known as a gatekeeper because he or she “keeps the gate” to more specialized forms of care offered within the HMO. In other words, an HMO member must receive a referral from a gatekeeper in order to access specialized providers.
Guarantor: The person responsible to pay the bill.
HCFA 1500 Form: A form required by Medicare and used by some private insurance companies and managed care plans for billing.
Health Care Provider: A person or entity that administers medical or health services. A provider is also any other person or organization who furnishes, bills, or is paid for health care in the normal course of business.
Health Maintenance Organization (HMO): An organization that provides comprehensive health care in a particular geographic area to people who voluntarily enroll and make regular and fixed payments to use the doctors, hospitals, etc., that belong to the organization.
Health Insurance Portability and Accountability Act (HIPAA): Legislation with the primary goal to make it easier for people to keep health insurance, protect the confidentiality and security of healthcare information and help the healthcare industry control administrative costs.
Hospice: A home providing care for the sick, especially the terminally ill.
Indemnity Health Insurance: A traditional health insurance plan with little or no benefit management, a fee-for-service reimbursement model, and few restrictions on provider selection.
Long Term Care: A continuum of medical and social services designed to support the needs of people living with chronic health problems that affect their ability to perform everyday activities.
Managed Care: A system of health care in which patients agree to visit only certain doctors and hospitals, and in which the cost of treatment is monitored by a managing company.
Medicaid: A program of medical aid designed for those unable to afford regular medical service and financed by the state and federal governments
Medicare: Is a national social insurance program, administered by the U.S. federal government since 1966, that guarantees access to health insurance for Americans aged 65 and older who have worked and paid into the system.
Non-Covered Charges: The charges for medical services denied or excluded by your insurance. You may be billed for these charges.
Non-Participating Provider: A doctor, hospital, or other health care entity that is not part of an insurance plan’s network.
Open Access: A term describing a member’s ability to self-refer for specialty care. These models allow patients to see a participating specialist without a referral.
Out-of-Network: This term typically refers to any doctors, hospitals or other healthcare providers considered to be non-participants by your insurance plan (HMO, POS, or PPO). Depending on your plan’s guidelines, services provided by out-of-plan providers may not be covered, or only covered in part.
Out-of-Pocket Costs: The most you will have to pay for covered medical expenses in a plan year through deductible and coinsurance before your insurance plan begins to pay 100 percent of covered medical expenses.
Outpatient Care: A type of care in which the patient is not hospitalized for 24 hours or more but who visits a hospital, clinic, or associated facility for diagnosis or treatment. See: Ambulatory Care
Participating Provider: A physician, clinic, hospital, or other health care entity that agrees to be a participating member of an insurance network. A participating provider will accept your insurance payment as payment in full, minus deductibles, co-pays and co-insurance.
Pre-existing condition: a medical condition that a patient has before he or she obtains a new health insurance plan.
Premium: Amount paid periodically to purchase health insurance benefits.
Primary Payer: The primary payer is the health insurance entity that makes the first payments upon a claim when a patient has more than one health insurance plan.
Referral: An approval that is needed that gives a health plan member authorization to receive care from a provider other than his or her primary care provider. HMO’s will often require a referral from a primary care physician before the patient may see a specialist.
Secondary Payer: The secondary payer is the health insurance entity that supplements the payments that the primary payer has already made upon a claim when a patient has more than one insurance plan.
State Children’s Health Insurance Program (SCHIP): a federal program funded by states and the federal government, which offers health insurance coverage for children not covered by state Medicaid-funded programs.
Third Party Administrator (TPA): An organization that administers health care benefits-including claims review, claims processing, etc.-usually for self-insured employers.
TRICARE: A health care program that provides civilian health benefits for military personnel, military retirees, and their dependents, including some members of the Reserve Component. It was formerly known as CHAMPUS.
Usual, Customary or Reasonable (UCR) Charge: A term used to refer to the commonly charged or prevailing fees for health services within a geographic area. Many insurers and managed care plans reimburse providers based on UCR charges. This term may be synonymous with a fee allowance schedule.