Following are some of the most common terms you
may hear that are associated with your insurance plans and medical
billing.
| Ambulatory Surgery |
Surgery done in the doctor’s
office or at a surgical center, and not requiring an overnight
stay. |
| Ancillary Providers |
Services over and above physician
services, including laboratory, radiology, home health and skilled
nursing facilities. |
| Authorization
|
Approval of care required before
a service is provided. Pre-authorization may be necessary before
hospital admission, or before care is given by non-HMO providers. |
| Balance Billing |
Billing a patient for charges not
paid by their insurance plan because the charges are above the
Usual and Customary Rate or because the insurer considered a
procedure medically unnecessary. |
| Carve-out Policy |
A contracted agreement between an
insurance company and another company which provides special
services to its members, such as prescription drugs or cancer
treatment. |
| Claim |
A record of medical services provided
to a patient and submitted by the provider to the insurance
company for payment. |
| Claims Review |
The method by which a patient’s
health care service claims are reviewed before reimbursement
is made. This is done to validate the appropriateness of services
given and that the cost is not excessive. |
| Coinsurance
|
A provision which limits the amount
of the coverage paid by an insurance plan to a certain percentage,
with the remaining costs paid by the member. |
| Co-payment |
The portion of a claim that a member
must pay out-of-pocket. |
| CPT-4 |
A 5-digit code that applies to medical
services delivered. |
| Deductible |
The amount an insured member must
pay before the insurance company pays benefits. |
| EOB (Explanation
of Benefits) |
A statement describing medical
benefits and account activity, including explanation of why
certain claims may or may not have been paid. |
| Exclusion |
Services or supplies not covered
under a health plan. |
| Fee Schedule |
A listing of the maximum fee which
a health plan will pay for services based on CPT billing codes. |
| ICD-9 |
A 3 to 5-digit number code describing
a diagnosis or medical procedure. |
| Inpatient |
A patient who is admitted to a hospital
and receives medical services from a physician during at least
a 24-hour period. |
| In-Network Provider |
Physicians and other service providers
who are contracted with a managed care plan. |
| Out-of-Network Provider |
Physicians who are not contracted
with a managed care plan. |
| Outpatient |
A patient who receives health care
services, but is not admitted to a hospital during a 24-hour
period. |
| Primary Care Physician |
A physician, usually a general, family
practitioner or internist, who delivers general health care,
and is most often the first doctor a patient sees. This physician
treats the patient directly, refers them to a specialist (or
secondary care physician) or admits them to the hospital. |
| Provider |
A physician, hospital, laboratory,
pharmacy or other organization that provides health care, goods
or services. |
| Pre-Certification |
Also known as pre-admission certification,
is the process of obtaining authorization from the health care
plan for routine inpatient and outpatient admissions. Failure
to obtain pre-certification may result in penalty to the provider
or the subscriber. |
| Referral Authorization |
Approval for a member to see a physician
or access services outside of the participating medical group. |
| Referral Physician |
A physician who sees a patient after
another doctor has sent them for specialty care or services. |
| Referring Physician |
A physician who sends a patient to
another doctor for specialty care or services. |
| Subscriber |
A person who enrolls in a health
care plan and agrees to pay for premiums, co-payments and deductibles
that are part of the plan. |
| Treating Physician |
A physician who provides care to
the patient while in the hospital, and usually works at the
hospital or comes in as a specialist. |
