Welcome to Medical Billing Knowledge-Base

In this section you can access to basics of Medical Billing , Abbreviations and terminologies used in Medical Billing, Policies, Procedures, rules & regulation and Guidlines from the key regulatory organizations of Medical Billing .

Medical Billing Process Abbreviations and Terminologies Policies & Procedures Rules & Guidlines Regulatory Authorties

Medical Billing Process

Medical billing is the process of generating healthcare claims to submit to insurance companies for the purpose of obtaining payment for medical services rendered by providers and provider organizations. After translating a healthcare service into a billing claim, the medical biller follows the claim to ensure the organization receives reimbursement for the work the provider performed. A knowledgeable medical biller can optimize revenue performance for the physician practice or healthcare organization.

Steps of Medical Billing Process

Patient Registration-The first step is to collect patients details such as Name DOB, gender, address, and phone number. The insurance information is also collected including Insurance Name, Policy ID or number and Out of pocket information. The demographic information and insurance details must be carefully noted and should be updated. Most of the practices are using medical billing software where patient details are recoded at the first encounter and it can be used for subsequent visits.

Coverage Verification-Insurance verification is the process of contacting the insurance company through any available resource including web portals , IVR and live call to check patient eligibility whether the patent have active coverage with insurance and health insurance company covers the required procedures. This process includes deductibles, policy status, plan exclusions, and other items that affect cost and coverage and are done before patient is treated. Verifying insurance coverage and benefits ensures that services provided will be covered by the insurance.

Claim Creation-Once patient visits the provider office and received services then charges for the services rendered are entered into the Medical Billing Software in predefined format before sending it to insurance company .Claim contains CPT codes, DX codes, Modifiers, Place of service , Patient, Insurance, Provider and Facility information.

Claim Scrubbing-Before claim submission to the insurance claim is thoroughly checked to ensure it is correctly entered and coded. Insurance ,patient and provider and facility information is correct. Wrong and in valid information may result in either reduced payment or claim rejection/Denial.

Claims Submission-After Scrubbing claim next step is to submit claim to the insurance company. Claim can either be submitted electronically or paper as per insurance requirements. Most of the insurances are accepting electronic claims and a few insurances still required paper claims. Claims can be submitted directly to the insurance companies or we can use third party vendors known as clearinghouse for claim submission.

Monitor Claim Adjudication-Once claim is being submitted to insurance next step is to keep eye on the adjudication cycle. First of all claims acceptance / rejection is checked and if claim is rejected , then after removing the error claim need to be resubmitted to insurance. also one need to check claim status frequently to keep track of it.

Payment Posting-Once claim is accepted by the insurance there is no objection on claim then insurance decides to pay the claim, either in the from of a paper check or electronic fund transfer . Payments are sent along with a summary called Explanation of Benefits (EOB) and Electronic Remittance Advice (ERA). This payment need to be recorded/posted in the provider Billing software in order to keep the record and for further patient billing process.

Denial Managment-Insurance company implemented several check to validate the claim received this may include patient information verification , CPT-Dx validation , Insurance and Doctor information verification and if claim information failed through any of these checks then insurance decide to deny claim either in full or partially. Upon receiving denial notice it should be posted in system for record purpose and then necessary action need to be taken resolve the denial and resubmit claim for the reprocessing.

AR Follow-up-The Important phase of medical billing is Accounts Receivable follow-up and this is the systematic approach to track the status for unpaid claims and take action on these claim in order to resolve these claim for final processing. Several tools including clearinghouse acknowledgements , Insurance Portals, IVR , Live calls are used to track the status and then required action need to be taken according to the claim status.

Patient Billing-Once the claim has been processed by all of the insurances then patient is billed for any outstanding balances which is mainly their Co-pay, Co-insurance and deductibles. The statement which generally includes a detailed list and charges of the procedures and services provided, the amount paid by insurances and the amount due from the patient and this statement usually mailed ,emailed or faxed to the patient to received the outstanding amount. Once patient pay the amount.

Abbreviations and Terminologies

Abbreviations

Below are most comman abbreviations used in Medical Billing and Coding.

Abbreviation/Acronym Full form /Defination
AA Anesthesia Assistant
AAA Area Agency On Aging
AAC Actual Acquisition Cost
ABA Applied Behavioral Analysis
ABN Advance Beneficiary Notice Of Noncoverage
ABP Alternative Benefit Plan
AC Action Code
ACA Patient Protection And Affordable Care Act
ACC Accountable Care Collaborative
ACF Administration For Children And Families
ACIP Advisory Committee On Immunization Practices
ACO Accountable Care Organization
ACS American Community Survey
ACT Ask The Contractor Teleconference
ADA Americans With Disabilities Act
ADD Attention Deficit Disorder
ADHD Attention Deficit Hyperactivity Disorder
ADJ Adjustment
ADL Activity Of Daily Living
ADMC Advance Determination Of Medicare Coverage
ADP Automated Data Processing
ADR Additional Development Request
ADS Automated Development System
AFDC Aid To Families With Dependent Children
AFO Ankle Foot Orthosis
AHRQ Agency For Health Care Research And Quality
AIC Amount In Controversy
AIDS Acquired Immune Deficiency Syndrome
ALJ Administrative Law Judge
ALS Advanced Life Support (Ambulance)
AMA American Medical Association
AMA  American Medical Association
AMP Average Manufacturer Price
ANSI American National Standards Institute
AOB Assignment Of Benefits
AOB  Assignment Of Benefits
AP Account Payable
APC Ambulatory Payment Classification
APG Ambulatory Patient Group
APR Automatic Password Reset
APRN Advanced Practice Registered Nurse
APS Annual Person Summary
AR Accounts Receivable
ARP American Rescue Plan
ARTS Addiction And Recovery Treatment Services
ASA American Society Of Anesthesiologists
ASAM American Society Of Addiction Medicine
ASC Ambulatory Surgical Center
ASCA Administrative Simplification Compliance Act
ASP Average Sales Price
ASPE Assistant Secretary For Planning And Evaluation
ATP Assistive Technology Professional
AVS Asset Verification System
AWP Average Wholesale Price
AWV Annual Wellness Visit
AZMESA Arizona Medical Equipment Suppliers Association
BBA Balanced Budget Act (Of 1997)
BBA 97 Balanced Budget Act Of 1997
BBM Bone Mass Measurements
BBRA Balanced Budget Refinement Act (Of 1999)
BCBS  Blue Cross Blue Shield
BCRC Benefits Coordination & Recovery Center
BE Beneficiary Eligibility
BENE Beneficiary
BHH Behavioral Health Homes
BHO Behavioral Health Organization
BHP Basic Health Program
BI Benefit Integrity
Big Sky AMES Association Of Home Medical Equipment Suppliers (Montana And Idaho)
BIP Balancing Incentive Payments Program
BIPA Medicare, Medicaid & Schip' Benefits Improvement & Protection Act Of 2000
BISC Benefit Integrity Support Center
BLS Basic Life Support (Ambulance)
BMI Body Mass Index
BOE Basis Of Eligibility
BP Benefit Protection
BPO Bureau Of Program Operations (Cms)
BRFSS Behavioral Risk Factor Surveillance System
CAC Contractor Advisory Committee
CAH Critical Access Hospital
CAHMI Child And Adolescent Health Measurement Initiative
CAHPS Consumer Assessment Of Health Care Providers And Systems
CAMPS California Association Of Medical Product Suppliers
CARC Claim Adjustment Reason Code
CARF Commission On Accreditation Of Rehabilitation Facilities
CARTS Chip Annual Reporting Template System
CB Consolidated Billing
CBA Competitive Bidding Area
CBIC Competitive Bidding Implementation Contractor
CBO Congressional Budget Office
CBT Cognitive-Behavioral Therapy
CC Condition Code
CCBHC Certified Community Behavioral Health Clinic
CCI Correct Coding Initiative
CCIIO Center For Consumer Information And Insurance Oversight
CCN Cms Certification Number
CCO Coordinated Care Organization
CCPD Continuous Cycling Peritoneal Dialysis
CCR Cost-To-Charge Ratio
CCW Chronic Condition Data Warehouse
CDC U.S. Centers For Disease Control And Prevention
CDE Certified Diabetic Educators
CDL Clinical Diagnostic Laboratory
CDPS Chronic Illness And Disability Payment System
CDT Current Dental Terminology
CEDI Common Electronic Data Interchange
CEHRT Certified Electronic Health Record Technology
CELIP Claim Expansion And Line Item Pricing
CERT Comprehensive Error Rate Testing
CEU Continuing Education Unit
CF Conversion Factor
CFR Code Of Federal Regulations
CGM Continous Glucose Monitor
CGS Cigna Government Services
CHAMPUS Civilian Health Medical Program Of The Uniformed Services
CHAMP-VA Civilian Health And Medical Program Of The Department Of Veterans Affairs
CHC Comprehensive Health Center
CHIP State Children Health Insurance Program
CHIPRA ChildrenHealth Insurance Program Re-Authorization Act
CHNA Community Health Needs Assessment
CIN Client Identification Number
CLCCP Comprehensive Limiting Charge Compliance Program
CLIA Clinical Laboratory Improvement Amendments Of 1988
CMC Comprehensive Managed Care
CMCS Center For Medicaid And Chip Services
CMD Contractor Medical Director
CMG Case Mix Group
CMHC Community Mental Health Center
CMIP Comprehensive Medicaid Integrity Plan
CMN Certificate Of Medical Necessity
CMR Comprehensive Medical Review
CMS Centers For Medicare & Medicaid Services
CMS  Centers For Medicare And Medicaid Services
CMS-1500 Health Insurance Claim Form
CNM Certified Nurse-Midwife
CNOM Costs Not Otherwise Matchable
CNS Clinical Nurse Specialist
CO Contracting Officer
COA Change Of Address
COB Coordination Of Benefits
COB/COBC Coordination Of Benefits Or Coordination Of Benefits Contractor
COBA Coordination Of Benefits Agreement
COBC Coordination Of Benefits Contractor
COBRA Consolidated Omnibus Budget Reconciliation Act Of 1985
COINS Coinsurance
COPPA Condition Of Prior Payment Authorization
CORD Childhood Obesity Research Demonstration
CORF Comprehensive Outpatient Rehabilitation Facility
COTS Commercial-Off-The-Shelf
CP Clinical Psychologist
CPAP Continuous Positive Airway Pressure
CPE Certified Public Expenditure
CPI Center For Program Integrity
CPI-U Consumer Price Index For All Urban Consumers
CPNP Certified Pediatric Nurse Practitioner
CPO Care Plan Oversight
CPS Current Population Survey
CPT Current Procedural Terminology. Cpt® Is A Registered Trademark Of The American Medical Association
CR Change Request
CRD Chronic Renal Disease
CRNA Certified Registered Nurse Anesthetists
CRNP Certified Registered Nurse Practitioner
CSHCN Children With Special Health Care Needs
CSI Claim Status Inquiry
CSR Cost-Sharing Reduction
C-Status Contractor-Determined Allowance
CSW Clinical Social Worker
CT Computerized Tomography
CTA Computerized Tomography Angiography
CWF Common Working File
CWF/MSP Common Working File/Medicare Secondary Payer
CY Calendar Year
DAB Departmental Appeals Board
DAC Dme Mac Advisory Committee
DC Doctor Of Chiropractic
DCN Document Control Number
DDE Direct Data Entry
DDS Doctor Of Dental Surgery
DEDUCT Deductible
DEFRA Deficit Reduction Act
DHHS Department Of Health And Human Services
DHRM Dsh Health Reform Methodology
DHS Designated Health Services
DIF Dme Information Form
DMD Dme Medical Director
DME Durable Medical Equipment
DME MAC Durable Medical Equipment Medicare Administrative Contractor
DME  Durable Medical Equipment
DMECS Durable Medical Equipment Coding System
DMEPOS Durable Medical Equipment, Prosthetics, Orthotics And Supplies
DMERC Durable Medical Equipment Regional Carrier
DO Doctor Of Osteopathy
DOB Date Of Birth
DOD Date Of Discharge
DOE Date Of Entitlement
DOJ U.S. Department Of Justice
DOR Date Of Receipt
DOS Date Of Service
DOS  Date Of Service
DP Doctor Of Podiatry
DPM Doctor Of Podiatric Medicine
DRA Deficit Reduction Act
DRG Diagnosis-Related Group
DSC Doctor Of Surgical Chiropody
DSH Disproportionate Share Hospital
DSM Diagnostic And Statistical Manual Of Mental Disorders
D-SNP Dual-Eligible Special Needs Plan
DSP Doctor Of Surgical Podiatry
DSRIP Delivery System Reform Incentive Payment
DSRIP PPS Delivery System Reform Incentive Payment Performing Provider System
DUR Drug Utilization Review
DX Diagnosis
DxCG Diagnostic Cost Group Risk Adjustment Model
E/M Evaluation And Management
E/M,E&M Evaluation And Management
EAC Estimated Acquisition Cost
EAPG Enhanced Ambulatory Patient Group
ECG Electrocardiogram
ECP Essential Community Provider
ED Emergency Department
EDI Electronic Data Interchange
EDISS Electronic Data Interchange Support Services
EDS Electronic Data Systems Corp.
E-FMAP Enhanced Federal Medical Assistance Percentage
EFT Electronic Funds Transfer
EGHP Employer Group Health Plan
EHB Essential Health Benefit
EHR Electronic Health Record
EI Economic Index
EIN Employer Identification Number
EKG Electrocardiogram
ELE Express Lane Eligibility
EMC Electronic Media Claim
EMR Electronic Medical Records
EMT Emergency Medical Technician
EMTALA Emergency Medical Treatment And Active Labor Act
EOB Explanation Of Benefits
EOMB Explanation Of Medicare Benefits
EPSDT Early And Periodic Screening, Diagnostic, And Treatment
EQR External Quality Review
EQRO External Quality Review Organization
ERA Electronic Remittance Advice
ERL Electronic Receipt Listing
ERN Electronic Remittance Notice
ERP Education Recognition Program
eRx Electronic Prescribing
ESI Employer-Sponsored Insurance
ESRD End-Stage Renal Disease
FAI Financial Alignment Initiative
FAQ Frequently Asked Question
FBI Federal Bureau Of Investigations
FCA False Claims Act
FCHCO Federal Coordinated Health Care Office
FCN Financial Control Number
FDA U.S. Food And Drug Administration
FERA Fraud Enforcement And Recovery Act
FFCRA Families First Coronavirus Response Act
FFP Federal Financial Participation
FFS Fee For Service
FH Fair Hearing
FI Fiscal Intermediary
FIDE SNP Fully Integrated Dual-Eligible Special Needs Plan
FISS Fiscal Intermediary Standard Systems (Part A Processing System)
FL Form Locator
FMAP Federal Medical Assistance Percentage
FMR Financial Management Report
FOA Family Opportunity Act
FOIA Freedom Of Information Act
FPG Federal Poverty Guidelines
FPL Federal Poverty Level
FQHC Federally Qualified Health Center
FR Final Rule
FRC Federal Records Center
FUL Federal Upper Limit
FY Fiscal Year (October 1-September 30)
FYE Full-Year Equivalent
GAO U.S. Government Accountability Office
GBA Government Benefits Association
GDP Gross Domestic Product
GEHA Government Employees Hospital Association
GHP Group Health Plan
GME Graduate Medical Education
GPCI Geographic Practice Cost Index
GPP Global Payment Program
HAH Healthcare Association Of Hawaii
HBP Hospital Based Physician
HCAC Health Care-Acquired Condition
HCBS Home- And Community-Based Services
HCC Hierarchical Condition Category
HCERA Health Care And Education Reconciliation Act
HCFA Health Care Financing Administration
HCFAC Health Care Fraud And Abuse Control Program
HCPCS Health Care Common Procedure Coding System
HCRIS Health Care Cost Report Information System
HCRP High-Cost Risk Pool
HCUP Health Care Cost And Utilization Project
HEAT Health Care Fraud Prevention And Enforcement Action Team
HEDIS Health Care Effectiveness Data And Information Set
HH Home Health
HHA Home Health Agency
HHS U.S. Department Of Health And Human Services
HIC or HICN Health Insurance Claim Number (Medicare Number)
HIDE SNP Highly Integrated Dual-Eligible Special Needs Plan
HIE Health Information Exchange
HIGLAS Healthcare Integrated General Ledger Accounting System
HIMR Health Insurance Master Record (Social Security)
HIO Health Insuring Organization
HIPAA Health Insurance Portability And Accountability Act
HIPPS Health Insurance Prospective Payment System
HIT Health Information Technology
HIU Health Insurance Unit
HME Home Medical Equipment
HMO Health Maintenance Organization
HMOA Health Maintenance Organization Act
HOPD Hospital Outpatient Department
HPSA Health Professional Shortage Area
HRA Health Risk Assessment
HRMS Health Reform Monitoring Survey
HRR Hospital Referral Region
HRSA Health Resources And Services Administration
HSI Health Services Initiative
HSIP Hpsa Surgical Incentive Payment
IACS Individuals Authorized Access To Cms Computer Services
IADL Instrumental Activity Of Daily Living
IBNRS Incurred But Not Reported Survey
ICD International Classification Of Diseases
ICD-10 International Classification Of Diseases, 10Th Edition
ICD-9 The International Classification Of Diseases, Ninth Revision
ICD-9-CM International Classification Of Diseases, 9Th Revision, Clinical Modification
ICF Intermediate Care Facility
ICF/ID Intermediate Care Facility For People With Intellectual Disabilities
ICN Internal Control Number
ICT Integrated Care Team
ICU Intensive Care Unit
ID/DD Intellectual Or Developmental Disabilities
IDE Investigational Device Exemption
IDPN Intradialytic Parenteral Nutrition
IDR Integrated Data Repository
IDTF Independent Diagnostic Testing Facility
IG Implementation Guide (Hipaa)
IGT Intergovernmental Transfer
IHS Indian Health Service
IIC Inflation-Indexed Charge
IIP Inflation Index Charge-Prevailing
IL Independent Laboratory
IMD Institutions For Mental Diseases
IME Indirect Medical Education
IMU Index Of Medical Underservice
Inpt Inpatient
IOL Intraocular Lens
IOM Institute Of Medicine
IOP Intensive Outpatient Program
IP Independent Psychologist
IPL Independent Physiological Laboratory
IPPB Intermittent Positive Pressure Breathing
IPPE Initial Preventive Physical Examination (Welcome To Medicare)
IPPS Inpatient Prospective Payment System
IPUMS Integrated Public Use Microdata Series
IRC Internal Revenue Code
IRF Inpatient Rehabilitation Facilities
IRP Inexpensive Or Other Routinely Purchased Dme
IRS Internal Revenue Service
IV Intravenous
IVR Interactive Voice Response
KAFO Knee Ankle Foot Orthosis
LADC Licensed Alcohol And Drug Counselor
LCD Local Coverage Determination
LCER Limiting Charge Exception Report
LCL Lowest Charge Level
LCMP Licensed Certified Medical Professional
LEA Local Education Agency
LFS Laboratory Fee Schedule
LGHP Large Group Health Plan
LIHP Low-Income Health Program
LIP Low Income Payment
LIS Low-Income Subsidy
LLP Limited License Practitioner
LM Licensed Midwife
LOC Level Of Care
LON Length Of Need
LOS Length Of Stay
LPN Licensed Practical Nurse
LPR Legal Permanent Resident
LSO Lumbar Sacral Orthosis
LTC Long Term Care
LTCF Long Term Care Facility
LTR Lifetime Reserve Days
LTSS Long-Term Services And Supports
LVN Licensed Vocational Nurse
MA Medicare Advantage
MA Plan Medicare Advantage Plan (Formerly Medicare+Choice Or Medicare Hmo)
MAC Medicare Administrative Contractor
MACBIS Medicaid And Chip Business Information Solutions
MACPAC Medicaid And Chip Payment And Access Commission
MACRA Medicare And Chip Reauthorization Act
MAE Mobility Assistive Equipment
MAGI Modified Adjusted Gross Income
MAMES Midwest Association For Medical Equipment Services
MAP Measure Applications Partnership
MA-PD Medicare Advantage Prescription Drug Plans
MAS Maintenance Assistance Status
MAT Medication Assisted Treatment
MAX Medicaid Analytic Extract
MBES/CBES Medicaid Budget And Expenditure System/State Children Health Budget And Expenditure System
MBI Medicaid Buy-In
MCCA Medicare Catastrophic Coverage Act
MCE Managed Care Entity
MCH Maternal And Child Health
MCHB Maternal And Child Health Bureau
MCO Managed Care Organization
MCPS Medicare Claims Processing System
MCPSS Medicare Contractor Provider Satisfaction Survey
MCS Multi Carrier System
MD Medical Doctor
MDE Major Depressive Episode
MDRP Medicaid Drug Rebate Program
MDS Minimum Data Set
MEC Minimum Essential Coverage
MEDIGAP A Medicare Complementary Insurance Program
Medi-Medi Program Medicare-Medicaid Data Match Program
MedPAC Medicare Payment Advisory Commission
MEDPARD Medicare Participating Physician/Supplier Directory
MEI Medicare Economic Index
MEMA Member Enrollment Mix Adjustment
MEPS Medical Expenditure Panel Survey
MEPS-HC Medical Expenditure Panel Survey Household Component
MEPS-IC Medical Expenditure Panel Survey Insurance Component
MEQS Medicaid Eligibility Quality Control System
MFAIC Medicare Fraud And Abuse Information Coordinator
MFCU Medicaid Fraud Control Unit
MFP Money Follows The Person
MFSDB Medicare Fee Schedule Database
MH/SUD Mental Health/Substance Use Disorder
MHPA Mental Health Parity Act Of 1996
MHPAEA Mental Health Parity And Addiction Equity Act Of 2008
MIA Medicare Inpatient Adjudication
MIC Medicaid Integrity Contractor
MIG Medicaid Integrity Group
MII Medicaid Integrity Institute
MIP Medicaid Integrity Program
MIPPA Medicare Improvements For Patients And Providers Act
MITA Medicaid Information Technology Architecture
MLN Medicare Learning Network
MLR Medical Loss Ratio
MLTSS Managed Long-Term Services And Supports
MM Medlearn Matters
MMA Medicare Modernization Act
MMCDCS Medicaid Managed Care Data Collection System
MMCO Medicare-Medicaid Coordination Office
MMIS Medicaid Management Information Systems
MMLR Minimum Medical Loss Ratio
MMNA Monthly Maintenance Of Need Allowance
MMP Medicare-Medicaid Plan
MMSEA Medicare, Medicaid, And Schip Extension Act Of 2007
MOA Medicare Outpatient Adjudication
MOE Maintenance Of Effort
MOMS Maternal Opiate Medicine Support Project
MOU Memorandum Of Understanding
MOUD Medications To Treat Opioid Use Disorder
MPFS Medicare Physician Fee Schedule
MPFSDB Medicare Physician Fee Schedule Data Base
MR Medical Review
MRA Magnetic Resonance Angiogram
MRADL Mobility Related Activity Of Daily Living
MREP Medicare Remit Easy Print
MRI Magnetic Resonance Imaging
MRN Medicare Remittance Notice
MRS Magnetic Resonance Spectroscopy
MS Maintenance And Servicing
MSA Metropolitan Statistical Area
MSIS Medicaid Statistical Information System
MSN Medicare Summary Notice (Notice To Beneficiaries)
MSO Management Service Organization
MSP Medicare Savings Program
MSTAT Medicaid State Technical Assistance Teams
MTS Medicare Transaction System
MUA Medically Underserved Area
MUE Medically Unlikely Edit
MUP Medically Underserved Population
MVPS Medicare Volume Performance Standard
NA Non-Assigned (Claim)
NADAC National Average Drug Acquisition Cost Survey
NAMCS National Ambulatory Medical Care Survey
NAMD National Association Of Medicaid Directors
NAMPS Nevada Association Of Medical Products Suppliers
NCANDS National Child Abuse And Neglect Data System
NCB National Competitive Bid
NCCI National Correct Coding Initiative
NCD National Coverage Determination
NCHS National Center For Health Statistics
NCPDP National Council For Prescription Drug Program
NDAB National Diabetes Advisory Board
NDC National Drug Code
NEDS Nationwide Emergency Department Sample
NEHRS National Electronic Health Records Survey
NEMT Non-Emergency Medical Transportation
NF Nursing Facility
NFLOC Nursing Facility Level Of Care
NH Nursing Home
NHAMCS National Hospital Ambulatory Care Survey
NHCMQ Nursing Home Case-Mix And Quality Demonstration
NHE National Health Expenditures
NHIS National Health Interview Survey
NHRA Nursing Home Reform Act
NHSC National Health Service Corps
NICU Neonatal Intensive Care Unit
NIDA National Institute On Drug Abuse
NIPT Non-Institutional Provider Team
NIRT National Institutional Reimbursement Team
NIS Nationwide Inpatient Sample
N-MHSS National Mental Health Services Survey
NMW Nurse Midwife
NOBA Notice Of Budget Authority
NOC Not Otherwise Classified
NON-PAR Non-Participating Provider
NOOH Notice Of An Opportunity For A Hearing
Noridian Noridian Healthcare Solutions
NOS Number Of Service
NP Nurse Practitioner
NPI National Provider Identifier
NPP Non-Physician Practitioner
NPPES National Plan And Provider Enumeration System
NPR Net Patient Revenue
NPRM Notice Of Public Rule Making
NPWT Negative Pressure Wound Therapy
NSC National Supplier Clearinghouse
NSCAW National Survey Of Child And Adolescent Well-Being
NSCH National Survey Of Childrens Health
NSCSHCN National Survey Of Children With Special Health Care Needs
NSDUH National Survey On Drug Use And Health
NSF National Standard Format
NSLP National School Lunch Program
N-SSATS National Survey Of Substance Abuse Treatment Services
NTIS National Technical Information Service
NUBC National Uniform Billing Committee
NUCC National Uniform Claim Committee
OA Other Adjustment
OACT Office Of The Actuary
OAS Office Of Audit Service Of The Department Of Health And Human Services
OASI Old-Age And Survivors Insurance Trust Fund
OB-GYN Obstetrician-Gynecologist
OBRA Omnibus Budget Reconciliation Act
OCC Occurrence Code
OCE Outpatient Code Editor
OCNA Other Carrier Name/Address
OCR Optical Character Recognition
OD Onset Date
ODWCC Outpatient Departmental Weight Cost-To-Charge
OE Operating Expenses
OFM Office Of Financial Management
OI Office Of Investigations
OIFO Office Of Investigations Field Office
OIG Office Of Inspector General
OLC Online Learning Center
OMB Office Of Management And Budget
OMCA Other Medicare Change Assessment
OMHA Office Of Medicare Hearings And Appeals
OMRA Other Medicare Required Assessment
OPD Outpatient Department
OPFS Outpatient Prospective Fee Schedule
OPM U.S. Office Of Personnel Management
OPPC Other Provider Preventable Conditions
OPPS Outpatient Prospective Payment System
OPT Outpatient Physical Therapy
OSC Occurrence Span Code
OT Occupational Therapy
OTAF Obligated To Accept As Payment In Full
OTC Over The Counter
OTP Opioid Treatment Program
OTPT Outpatient
OUD Opioid Use Disorder
P4P Pay For Performance
PA Physician Assistant
PACE Program Of All-Inclusive Care For The Elderly
PAHP Prepaid Ambulatory Health Plans
PAMES Pacific Association For Medical Equipment Services (Oregon And Washington)
PAOC Program Advisory And Oversight Committee
PAPE Payment Amount Per Episode
PAR Participating Physician
PAYERID Payer Identification (Number)
PBM Pharmacy Benefit Manager
PBRHC Provider-Based Rural Health Clinic
PC Professional Component
PCA Personal Care Attendant
PCC Primary Care Clinician
PCCM Primary Care Case Management
PCIP Primary Care Incentive Payment Program
PCMH Patient-Centered Medical Home
PCP Primary Care Provider
PCPCH Patient-Centered Primary Care Home
PCPCP Primary Care Partial Capitation Provider
PCRI Primary Care Rate Increase
PDAC Pricing, Data Analysis And Coding
PDL Preferred Drug List
PDMP Prescription Drug Monitoring Program
PDP Prescription Drug Plan
PDR Physician'S Desk Reference
PDT Purchased Diagnostic Test
PECOS Provider Enrollment, Chain And Ownership System
PEN Parenteral And Enteral Nutrition
PERM Payment Error Rate Measurement Program
PET Positron Emission Tomography
PFS Physician Fee Schedule
PHC Public Health Clinic
PHE Public Health Emergency
PHI Protected Health Information
PHP Prepaid Health Plan
PHSA Public Health Service Act
PHUP Partial Hospitalization Units Program
PI Program Integrity
PIHP Prepaid Inpatient Health Plan
PIM Program Integrity Manual
PIN Provider Identification Number
PM Program Memorandum
PMD Power Mobility Device
PMH Pregnancy Medical Home
PMP Primary Medical Provider
PMPM Per Member Per Month
PMPY Per Member Per Year
PNA Personal Needs Allowance
POA Present On Admission
POCI Provider Ownership Compensation Interest
POE Provider Outreach And Education
POE AG Provider Outreach And Education Advisory Group
POL Physicians Office Lab
POS Point Of Service
POV Power Operated Vehicle
PPC Provider Preventable Conditions
PPO Preferred Provider Organization
PPR Physician Payment Reform
PPS Prospective Payment System
PPTN Professional Provider Telecommunications Network
PPV Pneumococcal Pneumonia Vaccine
PQMP Pediatric Quality Measures Program
PQRS Physician Quality Reporting System
PR Patient Responsibility
PRAMS Pregnancy Risk Assessment Monitoring System
PRO Peer Review Organization
ProPAC Prospective Payment Assessment Commission
PROV Provider
PRR Patient Review And Restriction Programs
PRTF Psychiatric Residential Treatment Facility
PS&R Provider Statistical And Reimbursement Report
PSC Program Safeguard Contractor
PSO Provider Sponsored Organization
PSYCH Psychiatric Services
PT Physical Therapy
PTAN Provider Transaction Access Number (Formerly Pin)
Q&A Questions And Answers
QAP Quality Assurance Program
QC Quality Control
QDWI Qualifying Disabled And Working Individual
QHP Qualified Health Plan
QI Qualifying Individual
QIC Qualified Independent Contractor
QIO Quality Improvement Organization
QMB Qualified Medicare Beneficiary
QPP Quality Payment Program
QRTP Qualified Residential Treatment Program
RA Remittance Advice
RAC Recovery Audit Contract
RAD Respiratory Assistive Device
RAI Resident Assessment Instrument
RAP Resident Assessment Protocol
RARC Remittance Advice Remark Code
RBRVS Resource-Based Relative Value Scale
RBRVU Resource-Based Relative Value Units
RC Reasonable Charge
RCCO Regional Care Collaborative Organizations
RDU Renal Dialysis Units
REMIT Remittance Advice
REP PAYEE Representative Payee
RFB Religious Fraternal Benefit Society Plan
RFI Request For Information
RFP Request For Proposal
RHC Rural Health Clinic
RHHI Regional Home Health Intermediary
RIC Rehabilitation Impairment Categories
RN Registered Nurse
RNFA Registered Nurse First Assistants
RO Regional Office (Cms)
RPCH Rural Primary Care Hospital (Now Critical Access Hospital)
RPT Registered Physical Therapist
RRB Railroad Retirement Board
RT Respiratory Therapy
RUG Resource Utilization Groups
RVC Revenue Code
RVS Relative Value Scale
RVU Relative Value Unit
SACU Supplier Audit And Compliance Unit
SAD Self-Administered Drug
SADMERC Statistical Analysis Dmerc
SAMHSA Substance Abuse And Mental Health Services Administration
SB Swingbed
SBHC School-Based Health Center
SBIRT Screening, Brief Intervention And Referral To Treatment
SCHIP State Children'S Health Insurance Program
SCPFA Significant Correction Of A Prior Full Assessment
SCSA Significant Changes In Status Assessment
SDMI Severe Disabling Mental Illness
SE Special Edition
SED Severe (Or Serious) Emotional Disturbance
SEDD State Emergency Department Database
SEDS Statistical Enrollment Data System
SFY State Fiscal Year (July 1-June 30)
SGA Substantial Gainful Activity
SGS Safeguard Services
SHADAC State Health Access Data Assistance Center
SHIP State Health Insurance Assistance Programs
SHIPs State Health Insurance Plan
SIIS Supplemental Insurance Interface System (Crossover Claim)
SIL Special Income Level
SIM State Innovation Models Program
SIPP Survey Of Income And Program Participation
SLM Seat Lift Mechanism
SLMB Specified Low-Income Medicare Beneficiary
SLP Speech And Language Pathology
SMAC State Maximum Allowable Cost
SMD State Medicaid Director
SMI Serious Mental Illness
SMMM Severe Maternal Mortality And Morbidity
SMRC Supplemental Medical Review Contractor
SNAP Supplemental Nutrition Assistance Program
SNC Skilled Nursing Care
SNF Skilled Nursing Facility
SNP Special Needs Plan
SOFÂ Signature On File
SOS Site Of Service
SOTA State Operations And Technical Assistance Initiative
SPA State Plan Amendment
SPAN Occurrence Span Code
SPMI Serious Persistent Mental Illness
SPR Standard Paper Remittance
SPRY State Plan Rate Year
SSA Social Security Administration
SSBG Social Services Block Grant
SSDI Social Security Disability Insurance
SSI Supplemental Security Income
SSN Social Security Number
SSNRI Social Security Number Removal Initiative
ST Speech Therapy
SUD Substance Use Disorder
SUPPORT Act Substance Use-Disorder Prevention That Promotes Opioid Recovery And Treatment For Patients And Communities Act
SWG Swingbed
SWO Standard Written Order
TAN Treatment Authorization Number
TANF Temporary Assistance For Needy Families
TAP Technical Advisory Panel
TAT Turn-Around-Time
TBI/SCI Traumatic Brain Or Spinal Cord Injury
TC Technical Component
TCU Transitional Care Unit
TEFRA Tax Equity And Fiscal Responsibility Act
TEFT Testing Experiences And Functional Tools Demonstration
TENS Transcutaneous Electrical Nerve Stimulation
TIN Taxpayer Identification Number
TLSO Thoracic-Lumbar-Sacral Orthosis
TMA Transitional Medical Assistance
TMJ Temporomandibular Joint Dysfunction
T-MSIS Transformed Medicaid Statistical Information System
TNC Transportation Network Companies
TOB Type Of Bill
TOP Transitional Outpatient Payment
TOS Type Of Service
TPL Third Party Liability
TPN Total Parenteral Nutrition
TTWIIA Ticket To Work And Work Incentives Improvement Act
TTY Text Teletype
U&C Usual And Customary
UC Uncompensated Care
UCC Uncompensated Care Cost
UCR Usual And Customary Rate
UDS Uniform Data System
UIN Unique Identification Number (System Security)
UMWA United Mine Workers Association
UOS Unit Of Service
UPIC Unified Program Integrity Contractor
UPIN Unique Physician Identification Number
UPL Upper Payment Limit
UR Utilization Review
URA Unit Rebate Amount
USC Usual Source Of Care
USP U.S. Pharmacopoeia
USPSTF U.S. Preventive Services Task Force
UTMED Utah Medical Equipment Dealers
VA U.S. Department Of Veterans Affairs
VBP Value-Based Purchasing
VC Value Code
VFC Vaccines For Children Program
WAC Wholesale Acquisition Cost
WBT Web-Based Training
WC Workers Compensation
WCC Weighted Cost-To-Charge
WDI Working Disabled Individual
WEDI Workgroup For Electronic Data Interchange
WHO World Health Organization
WIC Special Supplemental Nutrition Program For Women, Infants, And Children
WPC Washington Publishing Company
YTD Year-To-Date
ZPIC Zone Program Integrity Contractor
Account number

This is the number assigned by provider office , Hospital or the billing software for every visit to relevent office/facility

Adjustment

The portion of charges for services rendered that provider has agreed to write off as per contractual adjustment.

Admission Date

The date on which patient got admitted to any facility for further treatment.

Advance beneficiary notice (ABN)

Notice provider gives to the patient before starting treatment informing that Medicare will not pay for the treatment or service and patient have decide whether to have the treatment and how to pay for it.

Allowed amount

insurance decides the fee for a particular service which is amount is usually less than the amount billed by the provider is called the allowed amount. Participating providers need to accept this amount while getting in contract with the insurance.

Ambulatory surgery

Outpatient surgery or surgery that does not require a saty in hospital for a night.

Ancillary service

The inpatient services patient receive beyond the room and board charges, such as laboratory tests, therapy and surgery

Appeal

This is the process by which provider can object to health plan decesion of No or less payment for care/service rendered by the provider to review and reconsider the claim.

Assignment of benefits

Agreement Patient signs to allow insurance plan to pay the provider directly for the services rendered.

Attending physician

The doctor who orders or provide the treatment is responsible for your care.

Authorization number

This is also called a Certification Number, Prior Authorization Number or Treatment Authorization Number which authorize the provider to provide specific services to patient.

Beneficiary eligibility verification

A way providers can retrieve information about whether you have insurance coverage.

Benefit contract

The legal agreement between a health plan and you. This contract establishes the full range of benefits available to you through your healthcare plan. A Benefits Contract is also sometimes referred to as a certificate of coverage or evidence of coverage.

Benefits

The extent to which your insurance coverage will pay for services provided to you. Benefits may describe what portion of the allowed amount may be due from you, the level to which they will pay for services provided by various providers, and what types of services they will or will not cover.

Bill/invoice/statement

A printed summary of your medical bill.

Brand-name drug

Drugs made and sold by a major drug company. Brand-name drugs may or may not be listed on a formulary. For any health need, there may be competing drugs from different companies. Your health plan formulary may list a specific brand-name drug if a price agreement has been made with that company. This brand-name drug will cost more than the generic version, but cost less than other brand-name drugs that are not on the formulary. If you buy brand-name drugs that are not on the formulary, you often pay more because your health plan pays more.

Certification number

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.

ChampVA

Insurance linked to military service. ChampVA shares the cost of certain medically necessary procedures and supplies with eligible beneficiaries. ChampVA does not have a network of health care providers, so eligible members can visit most authorized providers.

Claim

Your medical bill that is sent to an insurance company for payment.

Claim number

A number assigned by your insurance company to an individual claim.

Centers for Medicare and Medicaid (CMS)

The federal agency that runs the Medicare program. In addition, CMS works with the states to run the Medicaid programs.

Clinical research, clinical trial or research study(Also see “Experimental or investigational treatments”​)

Research conducted to evaluate the safety and/or effectiveness of a treatment, diagnostic procedure, preventive measure or similar medical intervention by testing the intervention on patients in a clinical setting. Participation in clinical research is voluntary. The informed consent form discusses who will pay the costs of services that are part of the clinical trial. Each study is different, but in many cases insurance will pay for medically necessary services that are part of the research study. Sometimes research services are paid for by the study. Check with your insurance plan or the study team to determine coverage.​

CMS-1500 form

The standard paper form used by healthcare professionals and suppliers to bill insurance companies.

COBRA (Consolidated Omnibus Budget Reconciliation Act)

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. COBRA provides certain former employees, retirees, spouses, former spouses and dependent children the right to temporary continuation of health coverage at group rates. The individual must pay the COBRA applies only under certain conditions, such as job loss, death, divorce or similar events. COBRA usually applies to group health plans offered by companies with more than 20 employees. premium cost to keep his/her insurance plan, but the costs are usually less expensive than individual health coverage.

Coding of claims

Translating clinical information from your medical record into numbers (such as diagnosis and procedure codes) that insurance companies use to pay claims.

Co-insurance

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. For instance, if the plan pays 70% of the allowed amount, the patient pays the remaining 30%. If your plan is a preferred provider organization (see "Preferred Provider Organization (PPO)") or other narrow network type of product, your co-insurance costs may be lower if you use the services of an in-network provider on the plan’s preferred provider list.​ Cal​l your insurance company for more information.

Commercial insurance plan

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. Commercial policies can be sold individually or as part of a group plan.

Consent for treatment

An agreement you sign that gives you permission to receive medical services or treatment from doctors or hospitals.

Co-payment (Co-pay)

A predetermined, fixed fee that you pay at the time of service. Copayment amounts vary by service and may vary depending on which provider (in-network, out-of-network, or provider type) you see. The amounts also may vary based on the type of service you are receiving (for instance, primary care vs. specialty care). For prescriptions, copayment amounts may vary depending on name-brand versus generic drugs. Call your insurance company for more information.

Coordination of benefits

How insurance companies work together when you have more than one insurance plan. A patient may be covered by more than one commercial insurance plan, such as through an employer as well as a spouse’s, parent’s or domestic partner’s employer. If you have more than one insurance plan, check with the secondary policy to find out how it covers expenses left over after your primary coverage has paid its part. (See "Secondary Insurance​")

Covered benefit

Services that your insurance company pays for in full or in part.

Covered days

The days that your insurance company pays for in full or in part.

CPT(Current Procedural Terminology) code

A 5-digit numbering system that helps standardize professional and outpatient facility billing. There is a CPT code for certain types of medical services. Using this code allows healthcare providers and insurance companies to communicate and track billing more efficiently.

Date of bill

Bill preparation date. It is not the same date as the date of service.

Date of service (DOS)

Treatment date.

Deductibles

The amount a patient pays before the insurance plan pays anything. In most cases, deductibles apply per person per calendar year. With preferred provider organizations (PPOs), deductibles usually apply to all services, including lab tests, hospital stays and clinic or doctor’s office visits. Some insurance plans waive the deductible for office visits. Some plans have service-specific deductibles.

Diagnosis-related groups (DRGs)

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.

Discharge hour

The time a patient is discharged from the hospital.

Discount

The dollar amount removed from your bill, usually because of a contract between your provider and your insurance company.

Drugs/self-administered

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.

Due from insurance

The amount your insurance company has agreed to pay.

Due from patient

The amount you owe.

Durable medical equipment (DME)

The medical equipment that can be used many times, or special equipment ordered by your doctor, usually for use at home.

Effective date

The date on which a Benefit Contract for coverage begins.

Eligibility

A determination of whether or not a person meets the requirements to participate in the plan.

Eligible payment amount

The medical services covered by an insurance company.

Emergency care

Care provided in a hospital Emergency Department.

Emergency department

The part of a hospital that treats patients with emergency or urgent medical problems.

Estimated insurance

An estimate of payments from your insurance company.

Enrollee

A person who is covered by health insurance.

Estimated amount due

The amount the provider estimates you or your insurance company owes.

Experimental or investigational treatments(Also see “clinical research, trial or research study”​)

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. If offered as part of a clinical research study, the study itself may cover the costs. Check with your insurance plan or study team if applicable to see if coverage is available for experimental or investigational treatments.

Explanation of benefits (EOB)

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. The EOB may detail the medical benefits activity of an individual or family.

Federal tax ID number

A number assigned by the federal government to doctors and hospitals for tax purposes.

Financial assistance program

Free or reduced rates for care provided to patients with demonstrated financial hardship.

Financial responsibility

The amount of your bill you have to pay.

Flexible spending account (FSA or flex account)

An employee benefit that allows a fixed amount of pre-tax wages to be set aside for qualified expenses. Qualified expenses generally include out-of-pocket medical expenses. The amount set aside must be decided in advance and employees lose any unused dollars in the account at the end of the year.

Formulary

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.

Generic drug

Drugs with proven benefits that cost less because they are not made by major drug companies and do not carry brand names. In almost all cases, you pay the least out of pocket for drugs in this group. Not all drugs have generic options.

Guarantor

The person responsible to pay the bill. The guarantor is always the patient unless the patient is an incapacitated adult or an unemancipated minor (under age 18), in which case, the guarantor is the patient’s parent or legal guardian.

Healthcare common procedure coding (HCPC)

A five-digit numbering system that helps standardize professional and outpatient facility billing. There is a HCPC code for certain types of medical services. Using this code allows healthcare providers and insurance companies to communicate and track billing more efficiently.

Healthcare provider

The party that provides medical services, such as hospitals, doctors or laboratories.

Health maintenance organization (HMO)

Health maintenance organization (HMO) (refers to health insurance) — These health insurance plans require enrolled patients to receive all their care from a specific group of providers (except for some emergency care). The plan may require your primary care doctor to make a referral before you can receive specialty care. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.

Health plan

A health plan refers to the type of health insurance you have. You may be part of a group health plan through your employer, you may have purchased an individual plan on the Health Insurance Exchange, be covered under workers’ compensation for a work-related injury, or have coverage through a government health plan such as Medicare and Medicaid. 

Health savings account (HSA)

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. Contributions are made into the account by the individual or the individual’s employer and are limited to a maximum amount each year. Unlike a flexible spending account, funds roll over and accumulate year after year if not spent.

HIPAA

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

High deductible health plan (HDHP)

A high deductible health plan (HDHP) with a health savings account (HSA) provides medical coverage and a tax-free way to save for future medical expenses. A high deductible health plan does not usually cover healthcare costs until the deductible has been met, which means you will be responsible for healthcare costs out-of-pocket until you meet your deductible. Once the deductible has been met, eligible healthcare expenses will be covered by the plan.

Home health agency

An agency that treats patients in their homes.

Hospice

The group that offers inpatient, outpatient and home healthcare for terminally ill patients.

Hospital-based billing

This refers to the charges for services rendered in a hospital outpatient clinic or department.

Hospital charge

The amount of money the hospital charges for a particular medical service or supply.

Incremental nursing charge

The charges for nursing services added to basic room and board charges.

Individual insurance

Health insurance purchased by an individual, not as part of a group plan.

In-network

A group of doctors, hospitals and other healthcare providers preferred and contracted with your insurance company. You will receive maximum benefits if you receive care from in-network providers. Depending on your insurance plan, your benefits may be reduced or not covered at all if you receive services from providers who​ are not in network.

Insurance waivers

The services excluded from your insurance policy, such as cancer care or obstetric/gynecologic or pre-existing conditions.

Insured group name

The name of the group or insurance plan that insures you, usually an employer.

Insured group number

A number that your insurance company uses to identify the group under which you are insured.

Insured’s name (beneficiary)

The name of the insured person, who is also referred to as the member.

Intensive care

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.

International Classification of Diseases, 10th edition (ICD-10-CM)

ICD-10-CM is the official system of assigning codes to diagnoses and procedures associated with hospital utilization in the United States.

Invoice/bill/statement

A printed summary of your medical bill.

Liability

The person or persons liable or under obligation for the bill.

Lifetime maximum coverage

The Affordable Care Act prohibits health plans from putting annual or lifetime dollar limits on most benefits you receive. Plans can put an annual dollar limit and a lifetime dollar limit on spending for healthcare services that are not considered essential health benefits. The essential health benefits include at least the following:

Long-term care

The care received in a nursing home.

Managed care

A type of insurance plan that requires patients to only see providers (doctors and hospitals) that have a contract with the managed care company, except in the case of medical emergencies or urgent care, if the patient is out of the plan’s service area.

Medicaid

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. For additional information, please see Your Health Insurance Coverage.

Medicare

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 (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). For additional information, including explanations of the different parts of Medicare, please see Your Health Insurance Coverage.

Medical record number

The number assigned by your doctor or hospital that identifies your individual medical record.

Medicare + Choice

A Medicare HMO insurance plan that pays for preventive and other types of healthcare provided by designated doctors and hospitals.

Medicare Advantage

A type of Medicare health plan offered by an insurance company that contracts with Medicare to provide you with all your Part A and Part B benefits, plus benefits that Original Medicare does not cover. For additional information, please see Your Health Insurance Coverage.

Medicare assignment

Providers who have accepted Medicare patients and agreed not to charge them more than Medicare has approved.

Medicare number

A Medicare card with a unique number is assigned to each person covered under Medicare. The number is used by providers for billing, eligibility and claim status. The Medicare Beneficiary Identifier (MBI) replaces the SSN-based Health Insurance Claim Number (HICN).

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

Assists with paying for doctor services, outpatient care and other medical services not paid for by Medicare Part A.

Medicare summary notice (MSN)

A statement that Medicare sends to you after they process a claim from a provider for services provided to you. Also called an Explanation of Medicare Benefits (EOMB). The EOMB lists the amount billed, the allowed amount, the amount paid to the provider and any copayment, deductible or co-insurance due from you. The EOMB may detail the medical benefits activity of an individual or family.

Medicare supplements or “Medigap” policies

Policies that supplement Medicare coverage. Most times, these policies pay the Medicare co-pays and deductibles, but nothing extra. Check with your supplemental insurance to find out how it coordinates benefits with Medicare.

Network

A group of doctors, hospitals, pharmacies and other healthcare experts hired by a health plan to take care of its members.

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 healthcare provider that is not part of an insurance plan, doctor or hospital network.

Observation

A hospital outpatient service ordered by a physician when the physician isn’t yet sure that you will need inpatient hospital care, but feels you need outpatient monitoring at the hospital in the meantime.

Out-of-network provider

A doctor or other healthcare provider who is not part of an insurance plan, doctor or hospital network. (See "Non-participating provider")

Out of network

A doctor, hospital or other healthcare provider who is not part of an insurance plan, doctor or hospital network. (See "Non-participating provider")

Out-of-pocket costs

The costs the patient is responsible for because Medicare or other insurance does not cover them.

Out-of-pocket maximum

The most money you will have to pay before your insurance company covers all costs. Each plan sets a dollar limit for the calendar year. Once that limit is reached, the plan will pay 100% of the allowed amount for eligible charges for the rest of the calendar year. Some insurance companies do not include certain costs in this limit, such as fertility treatments or prescription drugs. Other insurance companies increase the out-of-pocket maximum for care provided by out-of-network providers.

Over-the-counter drug

Drugs that do not require a prescription. They can be bought at a pharmacy or drugstore and be dispensed to patients, while at the hospital or doctor’s office.

Paid to provider

The amount the insurance company pays to your medical provider.

Paid to you

The amount the insurance company pays to you or your guarantor.

Participating provider

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.

Patient amount due

The amount your provider charges you for services received.

Pay this amount

The amount you owe toward your medical bill.

Physician practice

A group of doctors, nurses and physician assistants who work together.

Physician practice management

Non-physician staff hired to manage the business aspect of a physician practice. The staff includes personnel from patient financial services, medical records, reception, lab and X-ray technicians, human resources and accounting.

Point of service (POS)

A type of health plan that allows members to choose to receive services from a participating or non-participating network provider. There are usually higher costs to the patient if they receive services from a non-participating provider.

Policy number

A number your insurance company gives you to identify your contract.

Power of attorney

A power of attorney is a legal document that allows you to appoint another person (called an attorney-in-fact or agent) to act on your behalf and make certain decisions for you. A power of attorney may authorize your agent to make healthcare decisions for you (when you are unable to do so), buy or sell things, manage a business, invest money, cash checks and manage your financial matters generally. Your attorney-in-fact must be over 18 years old and can be a family member, relative, or other trusted person, but cannot be your physician. You may also name multiple attorneys-in-fact in the event your primary attorney-in-fact is unable to fulfill his/her duties. Your power of attorney can be written to either take effect immediately or to take effect at some time in the future and can be written to last either for a limited period of time or indefinitely; your power of attorney ends when you die. This information is provided as a courtesy of UW Medicine. If you have any additional questions regarding powers of attorney, please seek independent legal counsel.

Pre-admission approval or certification

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.

Pre-existing condition

A medical condition for which the patient has received treatment during a specific period of time prior to enrolling in a new insurance plan. This period (such as 30, 60, 90 days, 6 months, etc.) before enrollment is called the “look-back” period. “Treatment” is defined as receiving medical advice, recommendations, prescription drugs, diagnosis or treatment. Under the Affordable Care Act, p​re-existing condition exclusions are no longer allowed, with one exception: For individual plans (not purchased through an employer) that were in existence prior to 2010 and included such an inclusion.

Preferred provider organization (PPO)

A healthcare organization that covers a greater amount of the healthcare costs if a patient uses the services of a provider on their preferred provider list. Some PPOs require people to choose a primary care doctor who will coordinate care and arrange referrals to specialists when needed. Other PPOs allow patients to choose specialists on their own. A PPO may offer lower levels of coverage for care given by doctors and other healthcare professionals not affiliated with the PPO.

Prepayments

The money you pay before receiving medical care; also referred to as preadmission deposits.

Primary care network (PCN)

A group of doctors serving as primary care doctors.

Primary care physician (PCP)

A doctor whose practice is devoted to internal medicine, family and general practice or pediatrics. Some insurance companies also consider obstetricians or gynecologists primary care physicians.

Primary insurance company

The insurance responsible for paying your claim first, before the secondary insurance pays (for patients who are covered by more than one insurance).

Prior authorization number

A number stating that your treatment has been approved by your insurance plan. It is also referred to as an Authorization Number, Certification Number or Treatment Authorization Number.

Procedure code

A code given to medical and surgical procedures and treatments.

Prospective payment system (PPS)

A method of reimbursement in which Medicare payment is made based on a predetermined fixed amount. The payment amount for a particular service is derived based on the classification system of that service. (For example, diagnosis-related groups for inpatient hospital services.)

Provider contract discount

A part of your bill that your provider must write off because of billing agreements with your insurance company.

Provider

A hospital or physician who provides medical care to the patient.

Referral

Approval needed for care beyond that provided by your primary care doctor or hospital. For example, managed care plans (HMOs) usually require a referral from your primary care doctor to see a specialist or for special procedures.

Release of information

A signed statement from patients or guarantors that allows providers to release medical information so that insurance companies can pay claims.

Remittance advice

The explanation the hospital receives, usually with payment, from your insurance company after your medical services have been processed.

Responsible party

The person responsible for paying your hospital bill, usually referred to as the guarantor.

Revenue code

A billing code used to name a specific room, service or billing sum.

Same-Day surgery

A surgery performed as an outpatient service.

Secondary insurance

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. (See “Coordination of benefits.”)

Self-insured health plan

A group health plan in which the employer assumes the risk for providing healthcare benefits to their employees. The cost for paying claims is paid by the employer.

Self-pay

A person who pays out-of-pocket for healthcare services in absence of insurance.​

Service area

A geographic area where insurance plans enroll members. In an HMO, it is also the area served by your doctor network and hospitals.

Service begin date

The date your medical services or treatments began.

Service end date

The date your medical services or treatments ended.

Skilled nursing facility

An inpatient facility in which patients who do not require acute hospital care are provided with nursing care or other therapy.

Social security disability insurance (SSDI)

An income assistance program administered by the federal government for those with disabilities. The Social Security Administration (SSA) has its own definition of disability for various illnesses, such as kidney disease or diabetes. The application process can take many months. If approved, the monthly amount you receive is based on how much money you have paid into Social Security through payroll taxes. To be eligible for SSD, your disability must meet 1 of these conditions:

Have lasted or be expected to last at least 1 year.