Billing and Insurance Definitions

A document that informs a Medicare patient that the service(s) they are receiving may not be covered by traditional Medicare. (Excludes Medicare HMO's.)

A deduction in billing applied by your insurance carrier to medical services and treatments received.

The person or people eligible to receive benefits under an insurance policy or plan. Also known as the insured or the enrollee.

The amount an insured owes for covered services, including co-pays, co-insurance, deductibles, and balances due on billing amounts.

The document detailing the specific rules of your insurance policy.

Used when a patient has coverage from more than one insurance and/or government agency. The insurance providers work together to prevent duplicate payments (resulting in overpaying) on a patient's services. The process involves determining which policy is your primary insurance. See Primary Insurance.

A federal law requiring certain employers to offer qualifying employees a chance to continue health insurance coverage for themselves and/or their beneficiaries (i.e., family members) whose group health insurance has been stopped. Usually applies when qualified employees leave work for voluntary (resigning) or involuntary (termination, downsizing, company going out of business, etc.) reasons. Applies to employers with 20 or more eligible employees. Typically, COBRA makes continued coverage available for up to 18 or 36 months.

A type of cost sharing where the beneficiary and insurance provider share payment of approved charge for covered services in a specified ratio after payment of the deductible by the insured.

An amount expected to be paid by the patient at the time of service (or soon after) to cover their portion of the medical services rendered. Amounts vary, depending on your insurance policy. Check your policy for details.

"One patient - one guarantor" based statements that clearly shows the amount owed for all outstanding physician and hospital bills. If all your physician and hospital bills have the same guarantor, you will receive one statement. If you have different guarantors on any of your physician and/or hospital bills, you will receive one statement per guarantor.

The dates the beneficiary received the medical services referred to in the billing statement. See Healthcare Provider.

A type of cost sharing where the beneficiary pays a specified amount of approved charges for covered medical services before the insurer will pay for all or part of the remaining covered services. Common deductibles include: per year; per illness; per incident, etc., depending on coverage. Consult your policy for details on your specific deductible.

A notice sent by insurance companies to providers and/or beneficiaries showing the actions taken on charges, payments, adjustments, deductibles, co-pays, and explanation notes. Varies in form between payors and also between providers and beneficiaries.

Refers to the physical area or rooms of a hospital dedicated to a patient's registration, triage, and treatment of unscheduled emergency needs. Sometimes called ED (Emergency Department).

Adjustments made for qualified responsible parties to ease hardship due to low financial income. Financial need is established through assistance applications and financial guidelines.

See Insurance.

The individual or institution providing medical services (for example, a physician, hospital, or laboratory). Not all healthcare providers are "seen" by a patient, but provide supporting lab work to assist a patient's physician. These specialists must submit separate billings for their services. A healthcare provider is often mistaken to mean an insurance company providing healthcare insurance.

See Insurance.

Federal laws regarding rules for using, sharing, and protecting patient's health information.

An entity that provides, offers, or arranges for coverage of designated health services needed by plan members for a fixed, prepaid premium.

See Insurance.

Specifically, Health Insurance. Refers to all private and government plans in which a person pays a premium to cover themselves; and/or their spouse; and/or their children and other dependents against the costs of medical care. Health insurance is designed to reimburse health care providers for billed charges related to medical treatment. The purpose of health insurance, historically, is to absorb the majority of the costs to a patient for needed care. Patients can be covered by more than one insurance company. See COB (Coordination of Benefits).

The person or people eligible to receive benefits under an insurance policy or plan. Also known as the beneficiary.

The joint federal/state program that provides healthcare insurance to low-income families.

A federal health benefit program for people over 65 or those who are disabled.

A unique 8-digit number for each patient.

See Point of Service Plan.

Applies to PPO insurance plans. Coverage for treatment obtained from a non-participating provider. Typically, it requires payment of a deductible, plus higher co-payments and co-insurance than for treatment from a participating provider. See PPO (Preferred Provider Organization).

The portion of payments for covered health services to be paid by the patient, including co-payments, co-insurance, and deductible(s).

Any drug product/medicine that does not require a prescription under federal or state law. See Prescription Drug.

A formal payment plan set up with Patient Financial Services when the balance due cannot be entirely paid by the due date.

Usually an insurance company or governmental agency responsible for reimbursing a provider for a patient's incurred medical expenses. May be other organizations in case of research grants or studies.

A specialized professional employed at a hospital, "drug" store, grocery store, or any other pharmacy where prescription drugs are available. Pharmacists are responsible for overseeing the stocking, security, and distribution of controlled drugs to customers, which includes confirming prescriptions and insurance, counting pills, bottling, and mixing drugs, double-checking patient history against potential harmful drug mixes, discussing potential side effects, etc. See Prescription, Prescription Drug, Pharmacy, and Over-the-Counter (OTC) Drugs.

Any department in a hospital or retail outlet ("drug" store, grocery store, retail superstore, etc.) responsible for the distribution of prescription and over-the-counter drugs. See Over-the-Counter (OTC) Drugs, Pharmacist, and Prescription Drug.

A type of insurance policy allowing the insured to choose between accepting service from a participating or non-participating provider, with greater benefits associated with the use of participating providers.

See Subscriber.

A type of insurance policy that establishes contracts with providers of medical care. Providers under these contracts are referred to as a preferred provider. Usually, the benefit contract offers significantly better benefits and lower costs for receiving services from preferred providers, thus encouraging covered persons to use these providers. See also Out of Network.

In the medical industry, practice has two definitions: 1) (noun) Refers to an office where one or more physicians and/or professionals provide medical care to their patient. The doctor started his practice in 2001. Or 2) (verb) The pursuit of the medical profession. The doctor has practiced medicine for 7 years.

A review by an insurance company regarding the need for inpatient hospital care, done before the actual admission. See policy for details.

Any medical condition diagnosed or treated within a specified period immediately preceding the covered person's effective date of coverage of their current insurance policy. Pre-existing conditions may not be covered for some specified amount of time as defined in the certificate of coverage (usually 6 to 12 months). By law, individuals are required to satisfy a pre-existing waiting period only once, so long as they maintain continuous group health plan coverage with one or more carriers. See Pre-existing Condition Exclusion.

A practice of some health insurers to deny coverage to individuals for a certain period for health conditions that already exist when coverage is initiated. See Pre-existing Condition.

1) Amount paid periodically to purchase health insurance benefits; 2) Amount paid or payable in advance, often in monthly installments, for an insurance policy.

See PPO (Preferred Provider Organization).

An order—usually written on non-reproducible paper for security—presented to a patient by their medical doctor or other medical professional authorizing the dispensing of a controlled drug through a pharmacy. Prescriptions may also be "called in" by phone to a pharmacy for patient pick-up. See Pharmacist, Pharmacy, and Prescription Drug.

A drug controlled by the federal government, requiring a patient to receive authorization from a doctor or other medical professional (also known as a prescription) to allow access to a specific quantity of the drug. See Pharmacy, Pharmacist, Prescription, and Over-the-Counter Drug.

When an insured has more than one policy, the primary insurance is the policy determined to apply first, usually covering the majority of expenses before the secondary policy applies to the balance. See COB and Co-insurance.

An identifying number of our organization(s). The provider number differs depending on policy or payor.

Refers to any balance due on medical service or treatment for which the patient/guardian is responsible to pay. Refers both to a balance after insurance has paid out all benefits due, or to amount due on an entire account if no insurance existed at time of treatment.

The person who holds and/or is responsible for the medical insurance policy.