Glossary of Billing Terms

Billing Information

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 (IPPS) - 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 (PPO)s, 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 healthcare 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 healthcare services provided to the patient.