Medical Record Number –
The number assigned by your doctor or hospital that identifies your individual
medical record.
Medigap – A Medicare supplement (Medigap) policy is a private health insurance policy designed specifically to fill in some of the “gaps” in Medicare’s coverage when Medicare is the primary payers.
Mother baby Clause – Mother baby clause is rule in which a new born baby is covered under the policy of the mother for a period of 30 days from the date of birth.
Modifier – A modifier provides the means by which the reporting physician can indicate that a performed service or procedure performed has been altered (Change) by some specific circumstances, but not changed by definition or code assigned.
National Provider Identifier (NPI) – a 10-digit, intelligence-free, numeric identifier for providers and suppliers issued by CMS. Usage mandated by HIPAA.
Non-Participating Provider (out of network provider) – A doctor, hospital, or other healthcare provider that is not part of an insurance plan’s doctor or hospital network.
Observation – Usually charged by the hour. Type of service used by doctors and hospitals to decide whether the patient needs inpatient hospital care or can recover at home or in an outpatient area.
Out of Network – medical care sought from non participating providers; those providers who have not contracted with specific managed care plans.
Out-of-Pocket Costs – the patient’s share of the cost of health care services. This can include co-payment, co-insurance, or deductible. It is called Non-Covered Services.
Outpatient (OP) – services performed at a facility where the patient stays less than 24 hours and is not admitted to the facility.
Offset (Adjustment to next Claim) – When an insurance company makes a wrong/excess payment to its providers, it would adjust the amount in its subsequent claims. This is called an offset.
Participating Provider (In-network Provider) – Provider Means Doctor, Physician, Specialist, Nurse, Surgeon, Lab Technicians. A doctor or hospital who is contracted with the insurance company, has agreed to certain terms and payment conditions set by the insurance Plan.
Place of Service – This designates where the actual health services are being performed, whether it is home, hospital, office, and clinic.
Policy Number / Member identification number / HIC (Health Insurance Claim) number (Medicare) – A number that the insurance company gives the policy holder to identify the contract.
Pre-Existing Condition – A health condition or a medical problem that the insured has before signing up to receive insurance coverage. Some health insurers may not pay for these health conditions.
Primary Insurance Company – The insurance company who is responsible for paying the claim first. If patient has another insurance company, it is referred to as the Secondary Insurance Company.
Procedure code – The code used to describe the services / treatment provided by the doctor / hospital.
Provider – Any person (doctor, nurse, dentist) or institution (hospital or clinic) that provides medical care.
Provider Identification Number (PIN) – Assigned by the Insurance company / health plan to their contracted providers.
Rebill – To resubmit a claim.
Referral – permission from the primary care physician to seek services from a specialist for an evaluation, (Consultation) testing, and/or treatment. Managed care Plans (Private Insurance Plan) require this.
Release of Information – A signed statement from patients or guarantors that allows doctors and hospitals to release medical information so that insurance companies can pay claims.
Secondary Insurance – The insurance plan that is billed after the primary has paid or denied payment.
Specialist – A doctor who specializes in treating certain parts of the body or specific medical conditions. For example, cardiologists only treat patients with heart problems.
Superbill – a form listing procedure, service and diagnosis codes used to record services performed for the patient and the patient’s diagnosis for a given visit.
Supplemental – another name for secondary insurance. A Supplemental plan usually picks up the patient’s deductible and/or co-insurance.
Timely filing limit – The time frame that payers give to providers to submit the claims and get reimbursed. Start from calculated from Date of Service.
UB-92 / UB-04 (Uniform billing 92/04) / CMS 1450 - A form used by hospitals to file insurance claims for medical services.
UCR – Usual Customary & Reasonable Rate – The payment scale used in paying non-participating providers. Providers are paid according to the provider’s usual fee, the customary fee of other providers in the area, and the reasonable fee for the service.
Units of Service – Measures of medical services, such as the number of hospital days, pints of blood, kidney dialysis treatments, etc.
V Codes – ICD-9 (diagnosis) – codes assigned for preventive medicine services and for reasons other than disease or injuries.
Write off - Write off is the amount that is waived off by the provider. This is usually a loss borne by the provider due to various reasons.
W-9 FORM – A tax form which certifies an individual’s tax identification number. It is issued by IRS Internal Revenue Services used to Doctor.
Social Security Number – This is a Unique 9 digit number given by the Central Government through the Social Security Office for the purpose of identification.
Format: XXX XX XXXX 789 45 6123 3-2-4.
Medigap – A Medicare supplement (Medigap) policy is a private health insurance policy designed specifically to fill in some of the “gaps” in Medicare’s coverage when Medicare is the primary payers.
Mother baby Clause – Mother baby clause is rule in which a new born baby is covered under the policy of the mother for a period of 30 days from the date of birth.
Modifier – A modifier provides the means by which the reporting physician can indicate that a performed service or procedure performed has been altered (Change) by some specific circumstances, but not changed by definition or code assigned.
National Provider Identifier (NPI) – a 10-digit, intelligence-free, numeric identifier for providers and suppliers issued by CMS. Usage mandated by HIPAA.
Non-Participating Provider (out of network provider) – A doctor, hospital, or other healthcare provider that is not part of an insurance plan’s doctor or hospital network.
Observation – Usually charged by the hour. Type of service used by doctors and hospitals to decide whether the patient needs inpatient hospital care or can recover at home or in an outpatient area.
Out of Network – medical care sought from non participating providers; those providers who have not contracted with specific managed care plans.
Out-of-Pocket Costs – the patient’s share of the cost of health care services. This can include co-payment, co-insurance, or deductible. It is called Non-Covered Services.
Outpatient (OP) – services performed at a facility where the patient stays less than 24 hours and is not admitted to the facility.
Offset (Adjustment to next Claim) – When an insurance company makes a wrong/excess payment to its providers, it would adjust the amount in its subsequent claims. This is called an offset.
Participating Provider (In-network Provider) – Provider Means Doctor, Physician, Specialist, Nurse, Surgeon, Lab Technicians. A doctor or hospital who is contracted with the insurance company, has agreed to certain terms and payment conditions set by the insurance Plan.
Place of Service – This designates where the actual health services are being performed, whether it is home, hospital, office, and clinic.
Policy Number / Member identification number / HIC (Health Insurance Claim) number (Medicare) – A number that the insurance company gives the policy holder to identify the contract.
Pre-Existing Condition – A health condition or a medical problem that the insured has before signing up to receive insurance coverage. Some health insurers may not pay for these health conditions.
Primary Insurance Company – The insurance company who is responsible for paying the claim first. If patient has another insurance company, it is referred to as the Secondary Insurance Company.
Procedure code – The code used to describe the services / treatment provided by the doctor / hospital.
Provider – Any person (doctor, nurse, dentist) or institution (hospital or clinic) that provides medical care.
Provider Identification Number (PIN) – Assigned by the Insurance company / health plan to their contracted providers.
Rebill – To resubmit a claim.
Referral – permission from the primary care physician to seek services from a specialist for an evaluation, (Consultation) testing, and/or treatment. Managed care Plans (Private Insurance Plan) require this.
Release of Information – A signed statement from patients or guarantors that allows doctors and hospitals to release medical information so that insurance companies can pay claims.
Secondary Insurance – The insurance plan that is billed after the primary has paid or denied payment.
Specialist – A doctor who specializes in treating certain parts of the body or specific medical conditions. For example, cardiologists only treat patients with heart problems.
Superbill – a form listing procedure, service and diagnosis codes used to record services performed for the patient and the patient’s diagnosis for a given visit.
Supplemental – another name for secondary insurance. A Supplemental plan usually picks up the patient’s deductible and/or co-insurance.
Timely filing limit – The time frame that payers give to providers to submit the claims and get reimbursed. Start from calculated from Date of Service.
UB-92 / UB-04 (Uniform billing 92/04) / CMS 1450 - A form used by hospitals to file insurance claims for medical services.
UCR – Usual Customary & Reasonable Rate – The payment scale used in paying non-participating providers. Providers are paid according to the provider’s usual fee, the customary fee of other providers in the area, and the reasonable fee for the service.
Units of Service – Measures of medical services, such as the number of hospital days, pints of blood, kidney dialysis treatments, etc.
V Codes – ICD-9 (diagnosis) – codes assigned for preventive medicine services and for reasons other than disease or injuries.
Write off - Write off is the amount that is waived off by the provider. This is usually a loss borne by the provider due to various reasons.
W-9 FORM – A tax form which certifies an individual’s tax identification number. It is issued by IRS Internal Revenue Services used to Doctor.
Social Security Number – This is a Unique 9 digit number given by the Central Government through the Social Security Office for the purpose of identification.
Format: XXX XX XXXX 789 45 6123 3-2-4.