Glossary of Terms
Account Number
Number the patient's visit (account) is given by the hospital for documentation and billing purposes.Adjustment/Contractual Adjustment
Part of the bill that the hospital has agreed not to charge the patient because of billing agreements they have with the patient's insurance company.Admitting Diagnosis
The initial medical reason that was documented for the patient's condition.Advance Beneficiary Notice (ABN)
A notice the hospital gives the patient before they receive services when Medicare is not expected to pay for some or all of the services. The notice is given so that the patient may decide whether to have the treatment and how to pay for it if Medicare denies the charges. ABNs apply to patients with traditional Medicare only.Advance Directive
A written document, such as a living will or durable power of attorney that says how the patient wants medical decisions to be made if they lose the ability to make decisions for themselves.Ambulatory Care
Outpatient services.Ambulatory Care Charge
These fees support the physician's outpatient hospital practice and will be in addition to the physician's charge. Charges represent services like outpatient nursing care, appointments, receptionists, medical records, housekeeping and facilities operations.APC (Ambulatory Payment Classification)
A Medicare payment system for grouping and classifying similar outpatient services and procedures so Medicare can pay all hospitals the same amount.Assignment
An agreement the patient signs that allows your insurance to pay the doctor or hospital directly.Appeal
A process by which the patient, their doctor, or the hospital can object to the health plan's decision not to pay for medical services.Applied to Deductible
Part of the bill the insurance company requires the patient to pay the hospital. See also deductible.Assignment of Benefits
The doctor or hospital agrees to accept payment from an insurance company first and then bill the patient for any after-insurance balances. See also benefit.Authorization Number
A reference number stating that your treatment has been approved by insurance. Also called a certification number or prior-authorization number. See also preadmission approval/certification.Beneficiary
Someone who is covered under an insurance policy or plan.Beneficiary/Patient Liability
The portion patients must pay out-of-pocket for medical services, including co-payments, co-insurance, and deductibles. This is in addition to the portion paid by insurance.Benefit
The amount insurance pays for medical services.Billed Charges
The total charges that hospitals send to insurance companies/patients prior to any negotiated contracts or discounts being applied.Birthday Rule
Tthe Birthday Rule is approved by the National Association of Insurance Commissioners (NAIC). The Birthday Rule indicates that the plan of the parent whose date of birth (month and day) falls earlier in the calendar year is the primary plan for dependent children. For example, if the mother's birth date is June 10 and the father's birth date is April 23, the father's plan would be primary. If both parents have the same birth date, the health plan in effect for the longer period of time will be primary.Centers for Medicare and Medicaid (CMS)
The federal agency that operates the Medicare program and works with states to manage the Medicaid program (referred to as Medi-Cal in California, AHCCCS in Arizona and Medicaid in Nevada).Certificate of Coverage (COC)
A description of the health care coverage included in an insurance company's plan. The certificate of coverage is required by state laws and explains the health care coverage provided under the contract issued to the employer.Charity Care
Free or reduced-fee health care for patients who have financial hardship.Children's Health Insurance Program (CHIP)
A federal program jointly funded by states and the federal government, which provides medical insurance coverage for children not covered by state Medicaid-funded programs.
Claim
The medical bill the hospital sends to the insurance company on behalf of the patient.Clinic
An area in a hospital or separate building that provides medical care to regularly scheduled or walk-in patients for non-emergency care.Coding
A way hospital/physician's services and supplies are classified and defined into a set of predetermined numbers/codes for the purpose of billing.
Coding of Claims
A process through which diagnoses and procedures from the patient's medical record are translated into numbers (codes) that computers can process for payment.Co-Insurance
A type of cost sharing where the patient and insurance company share payment of the approved charge for covered services after payment of the deductible by the patient.Co-Insurance Days
Medicare coverage from day 61 to day 90 of continuous inpatient hospital stay. The patient is responsible for paying for a portion of those days. After the 90th day, the patient enters their lifetime reserve days.Collection Agency
A business that contracts with the hospital to collect money from patients for unpaid bills.Consolidated Omnibus Budget Reconciliation Act (COBRA)
A federal law that mandates employers with 20 or more eligible employees to provide continued health insurance under their group plan to terminated employees and their dependents. COBRA generally provides continued health insurance coverage for up to 18 or 36 months. COBRA beneficiaries may be required to pay 100 percent of the premium plus an administrative fee.Coordinated Coverage
Integrating benefits payable under more than one health insurance (for example, Medicare and retiree health benefits). Coordinated coverage is usually arranged so the insured benefits from all sources do not exceed 100 percent of allowable (disc)ounted) medical charges. Coordinated coverage may require patients to pay some deductible or co-insurance.Coordination of Benefits (COB)
The method for determining which insurance company is primarily responsible for payment when a patient is covered under more than one insurance plan. The insured's total benefits do not exceed 100% of the medical expenses.Co-pay
A fixed dollar amount that a patient must pay out-of-pocket. This is often associated with an office visit or emergency room visit. For example $5, $10, or $25.Covered Days
Days of the hospital stay that insurance company pays for in full or in part.Date Of Service (DOS)
The date(s) medical services were provided to the patient.Deductible
An agreed amount that a patient must pay before the insurance company will pay anything toward medical charges. Usually the amount must be met and paid by the patient each year.Denial
A decision by insurance company not to pay for part or all of a medical bill based on a lack of medical necessity or pre-admission approval/certification, terminated coverage, or other reasons. Denied amounts may be charged to the patient. See also appeal.Diagnosis Code
A code used for billing that describes the patient's illness.Diagnosis-Related Groups (DRGs)
A payment system of classifying patients on the basis of diagnosis. The DRG system categorizes payments into groups based on the principal diagnosis, type of surgical procedure, complications, and other indicators.Duplicate Coverage Inquiry (DCI)
A request to an insurance by another insurance to find out whether patient has other coverage (s)ee Coordinated Coverage.Durable Medical Equipment (DME)
Medical equipment that can be used multiple times and is ordered by a doctor for use at home. Examples include hospital beds, wheelchairs and oxygen equipment.EEG
Equipment or medical procedure that measures electricity in the brain.EKG/ECG
Equipment or medical procedure that measures how the heart works.Eligibility Verification
A way hospitals determine whether the patient has insurance coverage for the services they will provide.Employee Retirement Income Security Act of 1974 (ERISA)
This law regulates self-insured plans and makes them exempt from many state regulations that regulate other insurance plans.ERISA mandates financial standards and other requirements for group insurance plans.
Enrollee
Person who is covered by health insurance.Explanation of Benefits (EOB/EOMB)
The statement sent by the insurance company to the patient with a list of services provided, amount billed, and any insurance payments. This statement normally includes any payment due from the patient, such as co-insurance, deductibles, and co-payments.Fiscal Intermediary (FI)
A private company that has a contractual relationship with Medicare to process Medicare claims.Group Name
Name of the group (usually an employer) or insurance plan that insures the patient.Group Number
A number the insurance company uses to distinguish the group under which the patient is insured.Guarantor
Someone who either accepts or is legally responsible to pay for a given patient's hospital bill. The guarantor may or may not be the patient.HCFA/CMS 1500
A billing form used by doctors to file insurance claims for medical services.HCPCS codes
(HCFA Common Procedural Coding System) - A coding system used to describe outpatient services provided to the patient. HCPCS codes include CPT codes and other codes.Health Care Provider
A person or entity that provides medical services (e.g. a physician, hospital or laboratory).Health Insurance
Coverage that provides for the payment of medical services as a result of sickness or injury. It includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment.Health Insurance Portability and Accountability Act (HIPAA)
A federal law that governs standards for the security and privacy of patients' health information.Health Maintenance Organization (HMO)
A type of insurance plan that provides coverage of designated health services needed by plan members for a fixed, prepaid premium.Home Health Agency
An agency that offers medical care to patients in their homes.Hospice
A group that provides inpatient, outpatient, and home health care for terminally ill patients.Hospital Inpatient Prospective Payment System (IP)PS
Medicare's way of paying acute care hospitals for inpatient care. Prospective per-case payment rates are determined at a level to cover operating costs for treating a typical inpatient in a given Diagnosis-Related Groups (DRG).Inpatient (IP)
Patients who stay overnight in the hospital.International Classification of Diseases, 9th Edition (Clinical Modification) (ICD)-9-CM)
A coding system used to describe the patient's diagnosis and the procedures performed to treat them.Lifetime Reserve Days
Under Medicare provision, a patient has a lifetime reserve of 60 days of inpatient services they can receive after they receive more than 90 days of inpatient services in a benefit period. The patient must pay a daily co-insurance for each lifetime reserve day used. Additionally, lifetime reserve days can only be used once during a patient's life.Long Term Care
Medical care received in a nursing home.MCARE Non-Covered drug
See self-administered drug.Medicaid
A state insurance plan, funded by federal and state agencies, for low-income people who have limited or no insurance.Medically Necessary
Refers to services or supplies that are required to properly treat a specific medical condition. Services or supplies that are not considered medically necessary by insurance may be denied.Medicare
A federal health insurance program established for people age 65 and older. Additionally, Medicare covers some people under age 65 who have disabilities or end-stage renal disease (ESRD).Medicare + Choice
Gives Medicare patients the option of enrolling in a variety of private plans including health maintenance organizations (HMOs), preferred provider organizations (PPOs), provider-sponsored organizations (PSOs), private fee-for-service (PFFS) plans, and medical savings accounts (MSAs) with high deductible insurance plans. Under M+C plans, patients receive medical services without additional out-of-pocket costs.Medicare Number
A number given to every Medicare patient for tracking and billing purposes. This number can be found on the Medicare card.Medicare Part A
Medicare coverage that helps pay for inpatient hospital, home health, hospice, and skilled nursing facility services.Medicare Part B
Medicare coverage helps pay for physician services, medical supplies, and other outpatient services not paid for by Medicare Part A.Medicare Part D
Medicare coverage that helps pay for the costs of prescription drugs.Medicare Summary Notice (MSN)
Also called an Explanation of Medicare Benefits (EOMB). See explanation of benefits.Medicare Supplement Policy (Medsupp)
The insurer will pay a policyholder's Medicare coinsurance, deductible and co-payments for Medicare Part A and B and may provide additional supplement benefits according to the supplement policy selected. Also called Medigap or Medicare wrap.Medigap
Additional insurance purchased by Medicare beneficiaries to cover co-payments, coinsurance, deductibles, and services not paid for by Medicare Part A or B. Also known as Medicare supplement insurance.Network
A group of doctors, hospitals, and other health care providers that have a contract with an insurance plan to provide services to its patients.Non-Covered Charges
Charges for medical services denied or excluded by insurance. The patient may be billed for these charges. Also called "non covered amount."Non-Participating Provider (non-par)
A doctor, hospital, or other health care entity that is not part of an insurance plan's network. For medical services rendered by non-participating provider, the patient may be responsible for payment in full or higher costs. Also known as out-of-network provider.Observation
Type of medical service used by doctors and hospitals to determine whether the patient needs inpatient care, outpatient care or whether they can recover at home. Observation is usually charged by the hour and may include an overnight hospital stay.Out-of-Network (OON) Services
Medical services received from a non-participating provider. Coverage generally requires payment of a higher deductible, co-payment, and/or coinsurance than for medical services from a participating provider.Out-of-Pocket (OOP)
Payment for medical services due from the patient, including copayments, co-insurance, and deductible.Outpatient (OP)
A patient who does not need to stay overnight in a hospital. Outpatient services include lab tests, X-rays, and some surgeries.Over-the-Counter (OTC) Drug
Drugs that may be purchased at a pharmacy or drug store without prescription.Participating Provider
A doctor, hospital, or other health care entity that is part of an insurance plan's network. They agree to accept insurance payment for covered medical services as payment in full, less any patient liability.Patient Type
A way to classify patients based on the type of services they receive from the hospital, such as outpatient, inpatient, and Emergency, etc.Per Diem
Per day. Typically refers to charge or payment methods based on a set rate per day of medical care.Physician Participation
A way in which a physician agrees to accept an insurance company's payment level as payment in full. The bill is sent directly to the insurance company with payment made directly to the physician. This does not include patient's co-insurance, deductibles, and non-covered services.Point-of-Service Plan (POS)
A health insurance plan that allows the patient to choose to receive a medical service from a participating or non-participating provider, with different benefit levels with the use of participating providers. Policy Number - a number that the insurance company assigns the patient to identify the contract for coverage.Pre-Admission Approval/Certification (PAC)
An agreement by insurance company to pay for medical services. Physicians and hospitals ask the insurance company for this approval before providing medical services. Failure to get the approval often results in a penalty to the patient since the services may not be covered by insurance.Pre-Existing Condition (PEC)
Any health condition that has been diagnosed or treated within a certain time period immediately before the patient's effective date of coverage. Pre-existing conditions may not be covered for a specified time period as noted in the insurance company's certificate of coverage (usually 6 to 12 months).Pre-Existing Condition Exclusion
A practice of some health insurance companies to deny coverage to patients for a certain time period for medical conditions that already exist when coverage began.Preferred Provider Organization (PPO)
An insurance plan that has contracts with health care providers for discounted charges. Typically, the plan offers significantly better benefits and lower costs to the patients for services received from preferred providers.Premium
The amount paid, often in monthly payments, for an insurance policy.Prepayment
Money paid before receiving medical services.Prevailing Charge
A billing charge that is frequently made by physicians in a specific region or community.Primary Care Network (PCN)
A group of primary care physicians who have agreed to share the risk of providing medical care to their patients who are covered by a given health plan.Primary Care Physician (PCP)
A physician whose practice is devoted to internal medicine, family/general practice, pediatrics, or obstetrics/gynecology.Primary Insurance
The insurance plan responsible for paying the bill first. If a patient is covered by another insurance, it is referred to as the secondary insurance. See also coordination of benefits.Private Room and Board
A hospital room occupied by only one patient. These rooms may be more costly than semi-private rooms that are occupied by two patients. The patient may have to pay the price difference for a private room if the room is not deemed medically necessary.Procedure/CPT code
A coding system used to describe medical services and surgical procedures provided to the patient.Reasonable and Customary (R & C)
Commonly charged or prevailing fees for health services within a region or community.Referral
Approval needed for medical care beyond that offered by a primary care physician or hospital. For example, HMO plans typically require referrals from a primary care physician to see specialists.Release of Information
A signed statement from patients or guarantors that allows physicians and hospitals to release medical information so that insurance companies can pay medical bills.Revenue Code
A billing code used to categorize charges based on the type of service, supply, or procedure provided.Same-Day Surgery
Outpatient surgery.Secondary Insurance
Additional insurance that may pay some medical charges not covered by primary insurance. Payment is made according to the patient's insurance benefits, coverage, and coordination of benefits.Self-Administered Drug
For patients that are not admitted as an inpatient, these are drugs that do not require doctors or nurses to help the patient take them. Self-administered drugs may include ointments, inhalers, insulin, or any other medicine the patient may take at home.Self-Insured Plan
An insurance plan where financial responsibility for medical expenses is assumed by the group (usually an employer) rather than an insurance company. Self-insured plans are often managed by Third Party Administrators (TPA). Also known as self-funded plan.Skilled Nursing Facility (SNF)
A facility, either free-standing or part of a hospital, that provides care to patients seeking rehabilitation and other medical care that is less intense than that received in a hospital.Source of Admission
The way a patient was admitted to the hospital. For example, physician referral, transfer from another hospital, emergency room visit, etc.Specialist
A physician who specializes in treating specific body parts and medical conditions, or certain age groups. For example, cardiologists only treat patients with heart problems.State Children's Health Insurance Program (SCHIP)
A federal program funded by states and the federal government, which offers health insurance coverage for children not covered by state Medicaid-funded programs.Sub-Acute Care
A comprehensive inpatient care program for patients with a serious illness, injury, or disease who do not need intensive (acute care) hospital services. For example, infusion therapy, respiratory care, cardiac services, wound care, and rehabilitation services.Swing Bed
Refers to a bed for a patient who receives skilled nursing care in a non-skilled nursing facility.Third Party Administrator (TPA)
An independent entity (third party) that manages group benefits, claims and administration for a self-insured company or group.TRICARE
Insurance plan for active and retired military personnel, their families, and dependents. Also known as CHAMPUS.UB-92
A billing form used by hospitals to file insurance claims for medical services.Units of service
A way to measure quantity of medical services, such as the number of days in a hospital stay, pints of blood, etc.Usual, Customary, or Reasonable (UCR)
The amount insurance companies believe to be the common or prevailing charges for medical services provided in a region or community.Utilization Review (UR)
A formal assessment of the medical necessity, efficiency and/or appropriateness of health care services provided to the patient.No results found
Accident: Some examples of types of accidents for which the patient is being treated are as follows: Motor Vehicle Accident, Accident occurred at patient's own home, Accident - Crime Victim, Accident in someone else's house, Accident occurred in a public area, Drowning Accident, Job-related Accident, Self-inflicted Accident, Accident 3rd parties involved.
Accident Work Related: Answer whether the patient's accident was job related. The allowable values for this field are as follows: Yes, the patient's accident was job related. No, the patient's accident was not job related.
Address: Complete the mailing address. Approved abbreviations are:
N - North
E- East
S- South
W- West
LN - Lane
WY - Way
PKWY - Parkway
BLVD - Boulevard
APT- Apartment
PL - Place
SP- Space
RR - Rural Route
ST- Street
RT - Route
AVE- Avenue
PO BOX - Post Office Box
RD- Road
# - Number
Admitting Physician: The name of the doctor responsible for admitting the patient to a hospital or other inpatient health facility.
Advance Directive: Written ahead of time, a health care advance directive is a written document that says how the patient wants medical decisions to be made if they lose the ability to make decisions for themselves. A health care advance directive may include a Living Will and a Durable Power of Attorney for health care.
Beneficiaries: The name for a person who has health insurance through Medicare or an insurance plan.
Birth Date: Depending on what section you are answering this question, enterthe patient's, guarantor's or subscriber's birthdate in MM/DD/YYYY American format, where MM is the birth month, DD is the birth day, and YYYY is the birth year. Insurance priority is sometimes determined by birthdate order in the calendar year.
City: Enter the name of the city that is part of the mailing address.
Coordination Period (30 month coordination period): A period of time when the employer group health plan will pay first on a patient's health care bills and Medicare will pay second. If the employer group health plan doesn't pay 100% of the patient's health care bills during the coordination period, Medicare may pay the remaining costs.
Country: Enter the name of the country that is part of the mailing address.You do not need to answer this if it is for addresses in the U.S.A. United States of America.
Date or Time of Injury or Accident: Enter the date of the patient's accident. If a date is entered, the time of the accident must also be entered. Enter the accident date in MM/DD/YYYY format, where MM is the month, DD is the day, and YYYY is the year. Enter the accident time in HH:MM format, where HH is the hours and MM is the minutes.
Description of Injury/Illness: Describe the accident in a written account answering what happened? Was it a fall, was the patient struck by person or object or vehicle? What part(s) of the body was/were injured? Where was the location of the patient's accident? Home, work*,school*, public street, restaurant*, job site* and retailstore* are all examples of location. *Actual name and address of facility or site should be included.
Diagnosis: The name that describes the health problem that patient has or is seeking treatment for. The reason the patient is being treated.
End-Stage Renal Disease (ESRD) Permanent kidney failure that is severe enough to require lifetime kidney dialysis or a kidney transplant.
Employer Goup Health Plan (GHP): A GHP is a health plan that provides health coverage to employees, former employees, and their families, and is supported by an employer or employee organization.
Employment status: Depending on what section you are answering this question, identify the employment status of either the patient, the subscriber or the guarantor. Employed Full Time, Employed Part Time, Unemployed, Self-Employed, Retired, Active Military Duty.
Entitlement: The reason the patient became eligible for Medicare benefits. The reason can be by Age, Disability or End-Stage Renal Disease.
Ethnicity: Ethnic character, background, or affiliation. An ethnic group. Of or relating to a sizable group of people sharing a common and distinctive racial, national, religious, linguistic, or cultural heritage.
First Name: Depending on what section you are answering this question, enter the patient's, guarantor's or subscriber's first name. This name should be the full legal first name rather than a personal preference, nickname, or initial.
Gender: Enter the person's gender or sex. The allowable values are as follows: M - Male F - Female
Group Name:Enter the name of the insurance group or plan defined for the patient's account. Please refer to the insurance card for this information. Answers for this field can include letters, numbers, and spaces.
Group Number: Enter the identification number or code used for group coverage by the carrier or administration to identify the patient's insurance group. Please refer to the insurance card for this information. Answer can include letters, numbers, and spaces.
Guarantor: The person who ultimately accepts financial responsibility to pay the patient's bill. In most cases it is the adult patient receiving the service.If the patient is a child, the responsible party may be the child's parent or legal guardian. The guarantor should not be confused with the subscriber of the insurance. This may or may not be the same person.
Injury or Illness Due to an Accident: Some examples of types of accidents for which the patient is being treated are as follows: Motor Vehicle Accident, Accident occurred at patient's own home, Accident - Crime Victim, Accident in someone else's house, Accident occurred in a public area, Drowning Accident, Job-related Accident, Self-inflicted Accident, Accident 3rd parties involved.
Inpatient/Outpatient/Maternity Procedure: Answer Inpatient if your doctor has indicated you will be admitted to remain in a hospital bed for one or more days. Answer Outpatient if the service requires a stay of less than 24 hours or is done in an outpatient department. Answer Maternity if this procedure is related to the delivery of a newborn baby.
Insurance Information: Policy/Claim Number, Plan Group Number, and Group Name may be found on the insurance subscriber's insurance card.
Insurance Name: Enter the name of the insurance company that issued the policy. Please refer to the insurance card for this information. Generally found on the back of the insurance card where claims are mailed to.
Last Menstrual Period: The date your last period started. This is used to calculate your due date and the date from which your 40 weeks of pregnancy officially starts.
Last Name: Depending on what section you are answering this question, enter the patient's, guarantor's or subscriber's last name. This name should be the full legal last name rather than a personal preference, nickname, or initial. Examples: Mc Donald = mcdonald (no space) O'Brien = obrien (no apostrophe, no sapce) Smith-Jones = smith jones (use a space and not a hyphen) St. James = st james (do not use period)
Maiden Name: Enter the maiden name of a married female patient. This name should be the full legal last name rather than a personal preference, nickname, or initial.
Marital Status: Enter the marital status of the patient, for example: Single, Married, Separated, Divorced.
Materials You May Need to Complete the Registration: All applicable Health Insurance cards or documents which include the Insurance company name, insurance policy number and insurance billing address and insurance phone numbers. Birthdates, names, resident mailing addresses and phone numbers of the patient, subscriber and guarantor. Employer names, employer addresses and employer phone numbers for the patient, subscriber and guarantor. Name and address and phone number of person who is the Emergency/Primary contact for the patient.
Medicare: A federal program of healthcare insurance for the aged, totally disabled and those with end-stage renal disease. Benefits provided under title XVIII of the United States Social Security Act of 1965 as amended from time to time. Medicare part A pays for hospital services. Medicare part B is the voluntary part of medicare that pays a percentage of reasonable and customary costs for physician and ancillary services.
Medicare HMO: A type of Medicare managed care plan where a group of doctors, hospitals, and other health care providers agree to give health care to Medicare beneficiaries for a set amount of money from Medicare every month. In an HMO (Health Maintenance Organization),the beneficiary usually must get all their care from the providers that are part of the plan. There may be restrictions where the beneficiary may only go to certain hospitals or physicians.An alternative to the Original Medicare Plan which replaces the Original Medicare Plan and often named as Senior plans following the name of the insurance.
Medicare Managed Care Plan: These are health care choices (like HMOs) in some areas of the country. In most plans,the beneficiary can only go to doctors, specialists, or hospitals on the plan's list. Plans must cover all Medicare Part A and Part B health care. Some plans cover extras, like prescription drugs. Costs may be lower than in the Original Medicare Plan. An alternative to the Original Medicare Plan which replaces the Original Medicare Plan and often named as Senior plans following the name of the insurance.
Medicare Private Fee-for-Service plans. A private insurance plan that accepts people with Medicare.They may go to any Medicare-approved doctor or hospital that accepts the plan's payment. The insurance plan, rather than the Medicare program, decides how much it will pay and what the beneficiary will pay for the services they get. The beneficiary may pay more for Medicare-covered benefits. They may have extra benefits the Original Medicare Plan does not cover. An alternative to the Original Medicare Plan which replaces the Original Medicare Plan and often named as Senior plans following the name of the insurance.
Medicare Plan (Original): (sometimes called fee-for-service) - Everyone with Medicare can join the Original Medicare Plan. This plan is available nationwide. A pay-per-visit health plan that lets the covered patient go to any doctor, hospital, or other health care provider who accepts Medicare.You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance). The original Medicare plan has two parts: Part A (Hospital Insurance) and Part B (Medical insurance).
Medicare Part A: Hospital Insurance which pays for Inpatient care in hospitals, critical access hospitals, skilled nursing facilities, hospice care and some home health care.
Medicare Part B: Medical insurance which helps pay for Outpatient hospital care, doctor's services and some other medical services that Part A does not cover such as physical and occupational therapies, and some home health care. Medicare or surgical care that Medicare Part B helps pay for and does not include an overnight hospital stay, including:blood transfusions; certain drugs; hospital billed laboratory tests; mental health care; medical supplies such as splints and casts; emergency room or outpatient clinic, including same day surgery; and emergency room or outpatient clinic, including same day surgery; and x-rays and other radiation services.
MSP/Medicare Secondary Payer: Medicare Questionnaire: Questions mandated by the hospital's provider agreement with Medicare to ask all Medicare beneficiaries upon every inpatient and outpatient admission. In order to conform to the law and regulations, the provider (hospital) must verify MSP information prior to submitting a bill to Medicare. It is a guide to identify other payers which may be primary to Medicare. Beginning with part 1, answer each question in sequence. Comply with any instructions which follow an answer. If the instructions direct you to go to another part, answer, in sequence, each question under the new part.
Medicare + Choice (pronounced "Medicare plus Choice") plans. A Medicare program that givesthe patientmore choices among health plans. Everyone who has Medicare Parts A and B is eligible, except those who have End-Stage Renal Disease. There are two types of Medicare + Choice plans. Medicare + Choice plansare offered by private insurance companies (approved by Medicare) which provide care under contract to Medicare. Medicare + Choice plans include:1. Medicare Managed Care Plan and 2. Medicare Private Fee-for-Service plans. An alternative to the Original Medicare Plan which replaces the Original Medicare Plan and often named as Senior plans following the name of the insurance.
MSP Provision: This question pertains if the patient has dual coverage (i.e. entitlement based on Age and ESRD or Disability and ESRD) and the initial entitlement was Age or Disability.
- If a GHP was primary the day before they became eligible based on ESRD choose yes and the GHP will continue to be primary for the 30-month coordination period.
- If Medicare was primary the day before the patient became eligible for Medicare based on ESRD then Medicare is primary.
Name of Submitter: Enter the name of the person submitting the form, if you are completing this on behalf of someone else.
Newborn Pediatrician: A doctor specializing in the branch of medicine that deals with the care of infants and children and the treatment of their diseases.
Occupation: Depending on what section you are answering this question, enter the patient's, guarantor's or subscriber's occupation or job title. Enter a specific occupation, such as teacher, doctor, carpenter, etc. Homemaker and student are valid occupations. Enter the name and address of the student's school in the Employer field. Self-employed people should include their type of work.
Patient Relationship to the Subscsriber: This field contains a code indicating the patient's relationship to the subscriber. The subscriber is the person subscribing to or carrying the insurance plan for the patient case. How is the patient related to the subscriber? For example, if the subscriber is the mother of the patient, then the Patient Relationship to Subscriber is Child. Answer: how is the patient related to the subscriber? The patient is a child of the subscriber. Allowable values are as follows: Child, Parent, Step-Child, Patient is Insured (carries insurance on themselves), Foster Child, Grandparent, Grandchild, Spouse, Ward of the Court, Other.
Phone Number: Enter the telephone number requested in the question inlcuding the three-digit area code prefix that is associated with the telephone number and the seven-digit telephone number. For international telephone numbers, please include the country code and city code (routing) codes in front of the actual telephone number.
Policy Number: Enter the policy number for the patient's insurance plan. Please refer to the insurance card for this information. For Medicare plans, enter the patient's Medicare number. For all other plans, enter the insurance plan policy number. The answer can include letters, numbers, and spaces.
Primary Care Physician / Personal Care Physician: In an HMO plan, the PCP is responsible for providing covered healthcare services and for coordinating referrals to other network providers when specialized care is required.The PCP may be trained in family practice, internal medicine, pediatrics, or general practice.
Primary Insurance or Primary Payer: An insurance policy, plan, or program that pays first on a claim or bill from the hospital for medical care. This could be Medicare or other commercial health insurance.
Primary Language: What is the primary language of the patient? Enter another language if you prefer to have some documents provided to you in this language.
Prior Admission Date: Enter the admission date of the patient's last hospital stay. The day the patient began their last hospital inpatient stay.
Prior Discharge Date: Enter the discharge date of the patient's last hospital stay. The day the patient went home from their last hospital inpatient stay.
Prior Hospital:Enter the name of the hospital where the patient has been admitted just before this visit.
Prior Stay: Has the patient been admitted to a hospital previously? If yes, provide the name of the most recent facility and dates of admission and discharge from that facility.
Procedure: Something done to fix a health problem or to learn more about it. For example, surgery, tests, and putting in an IV (intravenous line) are procedures.
Procedure Authorization: Agreement by insurance company to pay for medical services. Physicians and hospitals ask the insurance company for this approval before providing medical services. Failure to get the approval often results in a penalty to the patient since the services may not be covered by insurance.
Procedure Date: Enter the appointment date that you have been given for your procedure to be performed. The date should be entered in MM/DD/YYYY format.
Procedure Time: Enter the appointment time that you have been given for your procedure to be performed.
Provider: A doctor, hospital, health care professional, or health care facility.
Referral: An OK from the patient's primary care doctor for them to see a specialist or get certain services. In many managed care plans, the patient needs to get a referral before they get care from anyone except their primary care doctor. If they do not get a referral first, the plan may not pay for their care.
Refresh: Refreshing the pre-registration web page will restart the timer on the alloted amount of time to fill out the form. The given time to fill out the pre-registration form is 24 minutes. Please note that refreshing a page will clear any data that has been entered already on the page! A web page can be refreshed several ways; by clicking the refresh icon (usually located at the top of your browser), the F5 key on your keyboard, or in Internet Exploer or Netscape browsers by clicking the View menu, then on refresh.
Relationship to Patient: Enter the emergency or primary contact's relationship to the patient. The allowable values are as follows: Mother, Sibling, Father, Friend, Spouse, Grandparent, Emancipated Minor, Child, Legal Guardian, Grandchild, Other
Religion: Enter the patient's religous preference.
Required Answers/Fields: Required fields are indicated by an asterisk to the left of the field description. An answer must be entered for each of these fields. The information is necessary for on-line pre-registration. If you do not have the required information, please gather the information before proceeding. The computer will not submit the registration without this data.
Secondary Insurance or Payer: An insurance policy, plan, or program that pays second on a claim or bill from the hospital for medical care. This could be Medicare, Medicaid, or other health insurance depending on the situation.
Social Security Number: The allowable values are the 9 numbers that make up a valid Social Security number or a valid Railroad Retirement number.
State: Enter the full name for the state (for the United States) or province (for Canada).
Submitter Phone Number: The phone number of the person submitting the form. This should be the best number to reach the subimtter wether mobile, home, work, or other. Please enter the three-digit area code prefix that is associated with the telephone number and the seven-digit telephone number. For international telephone numbers, please include the country code and city code (routing) codes in front of the actual telephone number..
Submitter Relationship to Patient: What is your relationship to the patient (example, spouse, child, friend, caregiver, etc.)?
Subscriber: The individual who signs and is responsible for a contract with a health insurance plan. The subscriber is the person subcribing to the insurance plan for the patient case. The subscriber is different from the enrollee, who is defined as anyone covered under the contract.
Type of Procedure: Something that is done to fix a health problem or to learn more about it. For example, surgery, tests, and putting in an IV (intravenous line) are procedures.
Type of Outpatient Service: Select the type of procedure you are seeking services for whether you are coming in for inpatient care or outpatient care.
Worker's Compensation: Insurance that employers are required to have to cover employees who get sick or injured on the job while performing job-related duties.
Zip or Postal Code:Enter the zip code. If the zip code is for a U.S. State or Possession, the zip code must be numeric. If the zip code is for a Canadian Province, the zip code must be six characters long and the last character must be a number.