Account Number – Number given by doctor or hospital for a
medical visit.
Advance Beneficiary Notice (ABN) – A notice the hospital or doctor gives the patient before the treatment, telling patient that Medicare will not pay for some treatment or services. The notice is given to the patient so that the patient may decide whether to have the treatment and how to pay for it.
Ambulatory Surgery – Outpatient surgery or surgery that does not require an overnight hospital stay. (within 24 Hours is called as Ambulatory Surgery)
Allowed Amount / Considered Amount – The dollar amount an insurancecompany deems fair for a specific service or procedure.
Appeal – Steps used when the payer denies a service the patient thinks is needed or refuses to pay for care that the patient has already received.
Assignment of Benefits – A written consent, signed by the policy / patient (in absence of the policy holder) to an insurance company, to pay benefits directly to the doctor or hospital.
Authorization Number – To be obtained by the provider before medical services are rendered (Provide) to the patient.
Beneficiary – Person covered by health insurance.
Beneficiary Eligibility Verification – A way for doctors and hospitals to get information about the patient’s insurance coverage or benefits.
Birthday Rule – Birthday rule is a rule in determining the primary and secondaryinsurance for a child when the parents are insured.
Ex – When father Insurance is in June Month and Mother Insurance is December That time Father Insurance is Primary and Mother insurance is Secondary (Or) When father Insurance is in December month and Mother Insurance is June that time Father insurance is Secondary and Mother insurance is Primary.
Capitation – System in which a physician is prepaid monthly.
Centers for Medicare and Medicaid Services (CMS) – A government agency that oversees the Medicare and Medicaid programs.
CDM – Charge Description Master – Inbuilt software where all billed amount for procedure codes are listed.
Claim – A medical bill or invoice sent to the insurance company.
Clean Claim – A claim is one which will pass through all front-end edits.
Clearing House – an entity (Organization) that forwards claims to insurance payers electronically.
Co Insurance – A percentage the patient is responsible to pay of the cost of the medical services.
Contractual Adjustment (Discount) – The part of the bill that doctor or hospital must write off (not charge patient) because of billing agreements with patient’s Insurance company.
Co-Ordination of Benefits (COB) – A Way to decide which insurance company is responsible for payment if patient has more than one insurance plan.
Co-Pay – A flat fee the patient pays each time for medical services. This is associated with managed care plans.
Covered Expenses – Covered services are those medical procedures the insurer agrees to pay for. They are listed in the policy.
CPT (Current Procedural Terminologies) – Codes used to report services and procedures. These are level 1 Codes under HCPCS.
ICD-9-CM – International Classification of Diseases-9th Version- Clearance Modification.
Credentialing – The process used by health insurance companies to examine and verify the medical qualifications of health care providers who want to participate in the network.
Date of Service – The date (s) when the patient was treated.
Deductible – The annual stipulated/fixed amount the patient is responsible to pay before any payment is issued by the insurance company.
Diagnosis Code – The Illness (Health Problem) of the patient the conclusion reached about a patient’s ailment by through review of the patient’s history, examination, and review of laboratory data.
Dependents: It means is Insured Person Family Members.
Durable Medical Equipment (DME) – Medical equipment that can be used many times, or special equipment ordered by your doctor, usually for use at home.
Ex – Wheel Chair, Neck Pain Belt, Crashers.
E-Codes – Codes used to describe external causes of injury, poisoning, or other adverse reactions affecting the patient’s health. Ex – Snake Bite.
Emergency Care – Care given for a medical emergency when the patient’s health is in serious danger when every second counts.
Enrollee/Guarantor/Subscriber/Policy Holder/Insured – A person who is covered by health insurance.
Explanation of Benefits / Remittance Advice (EOB/RA) – The notice sent to the patient and the doctor from patient’s insurance company after processing claims explaining the status.
EOMB – Explanation of Medicare Benefits (Medicare means is Primary Insurance)
Federal Tax ID Number – A number assigned by the federal government to doctors and hospitals for tax purposes.
Fee Schedule – A listing of the maximum fee that an insurance company will pay for a service based on the CPI Code.
Fraud – To purposely bill for services that were never given or to bill for a service that has a higher reimbursement than the service produced. Fraud includes offering and accepting kickbacks (Professional).
Abuse – The misuse of a person, substance, services such that harm is caused. Some of the healthcare abuses include excessive or unwarranted use of technology, pharmaceuticals and services, abuse of authority, abuse of privacy, confidentiality or duty to care.
Global Days – All surgical services have been assigned a “global time period” lasting up to a maximum of 90 days, for post operative care. All follow-up care for the surgery performed within the assigned global period will be considered part of the surgical reimbursement and not allowed separately.
HCPCS-Healthcare Common Procedure Coding System – A coding system used to report procedures, services, supplies, medicine, and durable medical equipment.
HIPAA – Health Insurance Portability and Accountability Act. This federal Act sets standards for protecting the privacy of your health information.
In Network – Medical care sought from participating providers within a managed care plan
Inpatient (IP) – A patient who has been admitted to a hospital and stays 24 hours or more.
Insurance Company – (Payer, Carrier, Insurer is Called Insurance Company) An Organization contracted with patient to pay for his health care expenses. Also known as Insurer.
Insured – One who has or is covered by an insurance policy.
Insured Group Name – Name of the group or insurance plan that insures the patient, usually an employer.
Insured Group Number –A number that your insurance company uses to identify the group under which the patient is insured.
Internal Control Number (ICN)/ Document Control Number (DCN) – A number assigned to the claim by the insurance company. It is also Claim Number.
Inprocess – The claim is received by the insurance company and is being reviewed (Verify or Check).
Itemized Statement/ I-Bill – An itemized statement provides a complete listing or detailed account of every service posted to a patient account. It includes the DOS, description of services, service code, charge amount, estimated insurance amounts and totals.
Late Charges – Charges discovered and processed after the initial final bill has been released.
Lock-box – Lock box is a banking term used when a hospital has a ‘lock-box’ number at the bank for the checks to come in.
Manual Claims Submission – the process of submitting health insurance claims via mail (Post).