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Account
- The number you ore given by your doctor or hospital
for a medical visit to thier office. Ambulatory Payment Classification (APC) - The basic unit of payment in the Medicare Prospective System for outpatient visits or procedures will be APC. Ambulatory Surgical Center (ASC) - An organization which provides surgical services on an outpatient basis for patients who do not need to occupy an inpatient, acute care hospital. Appeal - A process by which you, your doctor or your hospital Can object to your health plan when you disagree with the health plan's decision not to pay for your care. Approved Amount - The amount of the hospital's charge that a payer will recognize in calculating benefits. Authorization
- As it applies to managed care, authorization is the
approval of care, such as hospitalization. Pre-authorization may
be required before admission takes place or care is given by non-HMO
providers. Balance Billing - The practice of a provider billing a patient for all charges not paid for by the insurance plan. Beneficiary - Person covered by health insurance. Benefit - The amount of insurance your company pays for medical services. Benefits Period - Starts the day you are admitted to a hospital or skilled nursing facility (SNF) and ends when you haven't received hospital inpatient or SNF for 60 consecutive days. -
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- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Centers for Medicare and Medicaid Services - The U.S. Government agency with responsibility for the administration of the Medicare and Medicaid programs. Certification - Certification is the official authorization for use of services. Claims Review - The method by which an enrollee's health care service claims are reviewed before reimbursement is made. The purpose of this monitoring system is to validate the medical appropriateneness of the provided services and to be sure the cost of the service is not excessive. COB (Coordination of Benefits) - An agreeement to prevent double payment for services when a subscriber has coverage from two or more sources. The agreement determines which organization has primary responsibility for payment and which organizaiton has secondary responsibilty. Coinsurance - The cost sharing part of the bill thay you have to pay. For Mediare, the percent of the approvied charge that you have to pay either after you pay the Part A deductible, or after you pay the first $100 deductible each year for Part B. Contractual Adjustment - A part of your bill that your doctor or hospital must wirte off (not charge you) because of billing agreements with your insurance company. Co-payment - A type of cost sharing whereby the insured person pays a specified flat amount per unit of service or unit of time with the insurer paying the balance. Current Procedureal Technology (CPT)- A coding system used to describe what treatment or servies were given to you by your doctor. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Date of Service (DOS) - The date(s) when treatment was provided. Deductible - The portion of a subscriber's health care expenses that must be paid by the subscriber before any insurance coverage applies, commonly $100 to $300. Common in insurance plans and PPOS, uncommon in HMO's. Diagnosis (Dx) - The provider's determination of a patient's condition, sign or symptom, using the ICD-9-CM coding system. Diagnosis Code - A code used for billing that describes your illness. Direct Data Entry - Under HIPAA, this is the direct entry of data that is immediately transmitted into a health plan's computer. Diagnosis-Related Groups (DRG) - A statistical system of classifying any inpatient stay into groups for the purpose of payment. Durable Medical Equipment (DME) - DME is any medical equipment that can withstand repeated use, is useable at home, and is not beneficial to a person without an illness or injury. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Explaination of Benefits (EOB) - The notice that you receive from your insurance comapny after getting medical services from a doctor or hosital. It tells you what was billed, the payment amount approved by your insurance, the amount paid and what you have to pay. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - Fee-For-Service (FFS) - Refers to paying medical providers for individual services rendered. Fee Schedule - A listing of the maximum fee that a health plan will pay for a certain service based on CPT billing codes. - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Guarantor - The person who as agreed to pay the bill for medical services. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Health Maintenance Organization (HMO) - An insurance plan that pays for preventative and other medical services provided by a specific group of of participating providers. HCFA - 1500 - A claims form used by professionals to bill for services. Required by Medicare and generally used by private insurance companies. and managed are plans. HIPAA - Health Insurance Portability and Accountability Act. This federal act sets standards for protecting the privacy of your confidential health information. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - ICD-9-CM - International Classification of Disease (9th revision) - ICD9 is the abbreviation for international classification of diseases codified into 6-digit numbers. These are codes are used bymedical providers and insurance companies by which doctors are paid. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Length of Stay (LOS) - The lenght or number of days that an individual stays in an inpatient setting. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Managed Care Plans - An insurance plan that requires patients to see doctors and hospitals that have a contract with the managed care company, except in the case of medical emergencies or urgently needed care if you are out of the plan's service area. Medicaid - A program financed jointly by the federal government and the states, that provides health coverage for mostly low income women and children as well as nursing home care for low-income elderly. Levels of funding and benefits and the portion of low-income people covered bary widely from state to state. Medicare - The federal program providing health insurance for people aged 65 and older and for disabled people of all ages. Medicare Part A usually referred to as hospital insurance, helps pay for inpatient care in hospitals and hospices, as well as some skilled nursing costs. Medicare Part B helps to pay for doctor services, outpatient care and other medical services not paid for by Medicare Part A. Medigap - Insurance provided by carriers to supplement the monies reimbursed by Medicare for medical services. An individual may be required to pay the physician for the difference between Medicare's reimbursable charge and the physician's fee. Medigap is meant to fill the gap in reimbursement, so that the Medicare beneficiary is not at risk for the differences. Medicare Medical Savings Account - A Medicare helath plan option made up of two parts. One part is a Medicare SA Health Policy with a high deductible. The other part is a special savings account, called Medicare MSA. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Non-Covered Charges - Charges for medical services denied or excluded by your insurance. You may be responsible for payment of these charges. Non-Participating Provider - A provider who does not sign a Medicare participating agreement, and therefore is not obligated to accept assignment on all claims. - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - Original Medicare Plan - The traditional pay-per-visit arrangement that covers Part A and Part B services. Out-of-Network Provider - A doctor or other healthcare provider who is not part of an insurance plan's doctor or hospital network. Same as non-participating provider. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - -- - - - - - - - - - - - - - - -- - - - - - - - - - - - - Participating Provider - A doctor or hospital that agrees to accept your insurance payment for covered services as payment in full, minus your deductibles, co-pays and soinsurance amounts. Per Diem Reimbursement - Reimbursement of an institution, usualy a hospital, based on a set rate per day rather than on charges. Per Diem reimbursment can vary by service or can be a set rate. Pre-admission Certification - The practice of reviewing claims for hospital admission before the patient actually enters the hospital. This cost-control mechanism is intended to eliminate unnecessar hospital expenses by denying medically unnecessary admissions.
Point of Service Plan (POS) - An insurance plan
that allows you to choose doctors and hospitals without having
to first get a referral from your primary care doctor. Primary Insurance Company - The insurance company responsible for paying your claim first. If you have another insurance company, it is referred to as the Secondary Insurance Company. Private Fee-for-Service Plan - a private insurance plan that accepts Medicare beneficiaries. Procedure Code (CPT) - A code given to medical and surgical procedures and treatments. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - Referral - Permission from your primary care doctor to see a certain specialist or receive certain services. Resource Based Relative Value Scale (RBRVS) - A government mandated relative value system implemented in January 1992 that is used for calculating national fee schedules for services provided to Medicare patients. Physicians are paid on relative value units (RVUs) for procedures and services. The three components of each established value aer: work RVU, practice RVU, and malpractice expense RVU. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Secondary Insurance - Extra insurance that may pay some charges not paid by the primary insurancy company. Payment is dependent upon your insurance benefits and your coverage. Self-Insured or Self-Funded Plan - A health plan where the risk for medical cost is assumed by the company rather than an insurance company or managed care plan. Skilled Nursing Facility - An inpatient facility in which patients who do no need acute care are given nursing care or other therapy. Supplemental Insurance Policy - An additional insurance company that handles claims for deductibles and coinsurance reimbursement. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - Third Party Administrator (TPA) - An organization outside the insuring organization tha handles the administrative duties and sometimes utilization review. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - -- - UB-92 - A form used by hospitals to file insurance claims for medical servies. Usual, Customary or Reasonable (UCR) - A means of profiling prevailing fees in an area and reimbursing providers on the basis of that profile. Urgently Needed Care - Unexpected illness or injury that needs immediate medical attention, but is not life threatening. Utilization Review (UR) - Hospital staff who work with doctors to determine whether you can ge care at a lower cost or as an outpatient. |
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