Health insurance terminology
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| 12853840789 | Actuaries | Mathematicians who study trends & set the insurance premiums, deductibles, and co-pays | 0 | |
| 12853840790 | Adjustment Codes | Payer codes that explain why a claim is paid differently from how it is billed | 1 | |
| 12853840791 | Admitting Physician | A physician responsible for a patient's admission to a hospital | 2 | |
| 12853840792 | ADFC | "Aid to families with dependent children"; requires meeting specific income level for services | 3 | |
| 12853840793 | Aging Reports | Reports that specify the status of a claim and identify transactions requiring follow-up | 4 | |
| 12853840794 | Allowable charges | Also known as maximum allowable charge; provider payment that is the lower amount of the providers fee and the maximum the insurance company pays for the service | 5 | |
| 12853840795 | Ancillary medical provider | a limited-licensed professional who performs billable services | 6 | |
| 12853840796 | ANSII format | A complex electronic claims format that is capable of attaching medical records to the claim | 7 | |
| 12853840797 | APC | "Ambulatory patient classification"; Medicare payment system for facilities performing outpatient procedures | 8 | |
| 12853840798 | Appeal | A formal request for penalty reversal or a changed decision on a claim | 9 | |
| 12853840799 | ASC | "Ambulatory surgery center"; a freestanding facility that specializes in same-day surgery | 10 | |
| 12853840800 | Assignment of benefits | An allocation of who receives the insurance payment | 11 | |
| 12853840801 | Authorization number | The number is assigned by the insurance company when a decision is reached prior to the delivery of service. Therefore, service is medically necessary. | 12 | |
| 12853840802 | Authorized provider | A hospital, institution, physician or other professional who meets the licensing and certification requirements of TRICARE and is practicing within the scope of that license | 13 | |
| 12853840803 | Bad debt write off | A payment that is owed but not collectible | 14 | |
| 12853840804 | Balanced billing | The process of billing a patient for the balance after the insurance payment has been posted | 15 | |
| 12853840805 | beneficiary | The person entitled to insurance policy benefits | 16 | |
| 12853840806 | Benefit period | A Medicare patient readmission within 60 days of discharge; considered part of a previous hospitalization for calculating the Medicare part A patient financial responsibility. | 17 | |
| 12853840807 | Billing address | The mailing address for the patient or payer | 18 | |
| 12853840808 | Birthday rule | A rule used when both parents have insurance policies that cover a dependent child; specifies as the primary payer the parent whose birthday is the first in the calendar year | 19 | |
| 12853840809 | Capitation | Method of payment to a physician based on the amount of patients assigned by the medical plan not the actual costs. | 20 | |
| 12853840810 | Carrier | The medical plan that administers or underwrites a health benefit program | 21 | |
| 12853840811 | Carrier-direct | A billing method that allows a provider to submit claims directly to the insurance carrier | 22 | |
| 12853840812 | Case number | Payer assigned number that has to appear on each page sent with an appeal | 23 | |
| 12853840813 | Charge slip | Known as a superbill, encounter form, or routing form; documentation for financial, diagnostic, and treatment information | 24 | |
| 12853840814 | CHIP | "Children's health insurance program"; also known as title 21; a program that allows states to create health insurance programs for low-income children | 25 | |
| 12853840815 | Claim audits | A review for duplication of services or billing, and excessive services or billing | 26 | |
| 12853840816 | Claim edits | A review for completeness and accuracy of the claim form | 27 | |
| 12853840817 | Clean claim | A claim paid on the first submission by passing the payer claim edits and claim audits | 28 | |
| 12853840818 | Coinsurance | Known as co-payment, the percentage the Patient must pay the provider | 29 | |
| 12853840819 | Combination program | Combination of state, employer self-insured, and commercial workers compensation | 30 | |
| 12853840820 | Compliance monitoring | Identifying responsibilities related to accuracy and verification of the services provided | 31 | |
| 12853840821 | Concurrent payment audit | Auditing that's done at the time oayments are posted, to correctness of payments received. | 32 | |
| 12853840822 | Confidentiality | An ethical and legal guideline that specifies that certain information is not to be shared with others | 33 | |
| 12853840823 | COB | "Coordination of benefits"; a rule that determines how monies will be paid so that the total amount of the bill is not overlaid, for a patient with more than one insurance policy. | 34 | |
| 12853840824 | Coverage | A statement of medical conditions that a policy may or may not pay by the insurance | 35 | |
| 12853840825 | Day sheet | A chronological summary of transactions posted to patients ledgers on a given day | 36 | |
| 12853840826 | Deductible | The amount a patient pays for services before the insurance plan pays | 37 | |
| 12853840827 | Delinquent claim | Known also as pending claim; a claim for which payment is overdue | 38 | |
| 12853840828 | Demographic | Information about a person | 39 | |
| 12853840829 | Dependent | A person permitted serviced under an insured's health policy | 40 | |
| 12853840830 | Direct pay | A billing method in which the patient pays for the services provided | 41 | |
| 12853840831 | Dirty claim | A denied or rejected claim | 42 | |
| 12853840832 | Downcoding | Also called under coding; selecting a code at a lower level than the services required | 43 | |
| 12853840833 | Duplicate claim | Also called double billing; resubmission of identical claims without changes | 44 | |
| 12853840834 | EDI | "Electronic data interchange"; a process used for sending electronic claims | 45 | |
| 12853840835 | EOB | "Explanation of benefits"; a notification of decisions related to a claim | 46 | |
| 12853840836 | EOMB | "Explanation of Medicare benefits"; a notification of decisions related to a Medicare claim | 47 | |
| 12853840837 | Episode of care reimbursement | A single fee foe all services associated with the procedure or illness | 48 | |
| 12853840838 | Exclusion | A condition not covered by an insurance policy | 49 | |
| 12853840839 | fee-for-service | A billing method in which a price is charged for each individual service | 50 | |
| 12853840840 | Financial hardship discount | A discount for which a patient have financial difficulties signs a waiver that is put in his or her financial file,and for which the physician accepts what the insurance pays and writes off the portion owed by the patient | 51 | |
| 12853840841 | Facial intermediary (FI) | "Facial intermediary"; an insurance carrier that administers medical plans for a specific region | 52 | |
| 12853840842 | Global period | A time frame when all care related to a procedure or service is considered part of the coding report the procedure and may not be billed separately | 53 | |
| 12853840843 | Health insurance | A contractor that provides money to cover some or all of the cost of medically necessary services | 54 | |
| 12853840844 | HIPAA | "Health insurance portability and accountability act of 1996"; a federal law that governs a variety of health insurance billing regulations | 55 | |
| 12853840845 | HMO | "Health maintenance organization"; a managed care plan | 56 | |
| 12853840846 | IME | "Independent medical examination"; a second opinion at is requested by a third-party payer such as workers compensation or disability insurance, and that is usually performed for confirmation of a level of impairment or injury | 57 | |
| 12853840847 | Indemnity insurance plan | A fee for service plan; the purest form of commercial insurance, in which a patient directs his or her own care and pays a percentage of the cost | 58 | |
| 12853840848 | IDS | "Integrated delivery system"; a managed care organization that integrates all aspects of patient care under one delivery system | 59 | |
| 12853840849 | Indirect payer | A third party payer; an insurance company that pays for the fee for service instead of the patient | 60 | |
| 12853840850 | IPA | "Independent practice association"; an HMO contract with physician who maintain his or her existing practice | 61 | |
| 12853840851 | Kyle provision | A provision included in the 1997 BBA that allows providers who opted out of the Medicare program to enter into private contracts with Medicare recipients under special rules | 62 | |
| 12853840852 | Lifetime reserve | 60 extra days of hospital coverage that a Medicare coverage patient may use once if needed | 63 | |
| 12853840853 | Limited charge | 115% of the allowable charge billed for nonparticipating providers | 64 | |
| 12853840854 | Limited fee charge | A fee set at a maximum of 15% above the nonPAR Medicare approved rates | 65 | |
| 12853840855 | Line item posting | An accounting method in which every payment posted to the exact transaction for which payments are received. | 66 | |
| 12853840856 | Locality code | A 3 digit number that represents a group of zip codes | 67 | |
| 12853840857 | Maximum allowable fee | An established a physician may charge for a service | 68 | |
| 12853840858 | MCO | "Managed care organization"; a prepaid managed health plan | 69 | |
| 12853840859 | MDC | "Major diagnostic categories"; diagnostic code groups that are similar or related by treatment, diagnosis, or length of stay in a hospital setting | 70 | |
| 12853840860 | Medi / Medi | Also known as 18/19 or care / caid; a combination of Medicare and Medicaid programs available to Medicare eligible patients whose income is below poverty level | 71 | |
| 12853840861 | MFS | "Medicare fee schedule"; a list of Medicare approved fees for provider and physician services | 72 | |
| 12853840862 | MMI | "Maximum medical improvement and impairment rating"; usually, a percentage of total body function measurement assiociated with long-term impairment | 73 | |
| 12853840863 | MSN | "Medicare summary notice"; also known as Medicare remittance notice (MRD); an explanation of benefits remittance | 74 | |
| 12853840864 | MTF | "Military treatment facility"; a healthcare facility for members of the armed forces | 75 | |
| 12853840865 | National conversion factor | The figure multiplied by the relative value unit (RVU) into a payment amount | 76 | |
| 12853840866 | NonPAR | "Nonparticipating provider"; a physician that does not agree to accept the Medicare approved rate for services provided to Medicare patients | 77 | |
| 12853840867 | No-show | A patient who fails to call or arrive for a scheduled appointment | 78 | |
| 12853840868 | NPI | "National provider identification"; identification number that is to replaced the UPIN and PIN systems for submitting claims to health insurance programs | 79 | |
| 12853840869 | NSF Format | A simple form of sending electronic claim data; a form that can not submit supporting documentation with the claim | 80 | |
| 12853840870 | OIG / HHS | "Office of inspector general, department of health and human services" | 81 | |
| 12853840871 | Outliers | Claims that are outside the normal statistical patterns for the region | 82 | |
| 12853840872 | Out of plan | Services performed where there is no contact agreement with the medical plan of the patient | 83 | |
| 12853840873 | Out of picket expenses | Money the patient must pay for services | 84 | |
| 12853840874 | PAR | "Participating provider"; a physician who has signed a contract with a medical plan and has agreed to accept the fee schedule for services provided to patients | 85 | |
| 12853840875 | Patient account ledger | A permanent financial record of transactions for a patient | 86 | |
| 12853840876 | Patient account number | An internal identification number assigned by a practice for each patients financial record | 87 | |
| 12853840877 | Patient discount | A discount given to self-pay patients; can not be lower than the Medicare fee schedule | 88 | |
| 12853840878 | Patient eligibility | Contacting and verifying coverage of a patient to verify that the policy information is accurate and that coverage is active | 89 | |
| 12853840879 | Patient supplied information | The billing information for the top half of the insurance claim form | 90 | |
| 12853840880 | Penalized claim | A claim that does not pass the claim edits or audits; results in a reduction in payment | 91 | |
| 12853840881 | Pigeonholing | Using a short list of diagnosis codes for all patients, even when the codes don't match the actual diagnosis or condition | 92 | |
| 12853840882 | PIN | "Physician / provider identification number"; a unique number given by the insurance company that identifies the provider | 93 | |
| 12853840883 | Place of service codes | Codes that identify where the service is provided | 94 | |
| 12853840884 | Policyholder | Also known as the subscriber or beneficiary; the purchaser of the health insurance policy | 95 | |
| 12853840885 | POS | "Point of service"; allows HMO patients limited coverage for out of plan providers | 96 | |
| 12853840886 | PPO | "Preferred provider organization"; a managed care medical plan | 97 | |
| 12853840887 | Preauthorization | Obtaining prior approval before a service is provided | 98 | |
| 12853840888 | Pre existing condition | Any condition for which a person has received prior treatment | 99 | |
| 12853840889 | Premium | A free paid at regular intervals by the policyholder | 100 | |
| 12853840890 | Primary payer | The legally first billable insurance when more than one insurance policy is available | 101 | |
| 12853840891 | Professional courtesy | A decision by a physician to see a patient at no charge | 102 | |
| 12853840892 | Provider- supplied information | The billing information for the bottom half of the insurance claim form | 103 | |
| 12853840893 | PSO | "Provider sponsored organization"; a Medicare managed care plan | 104 | |
| 12853840894 | Qui tam | Provisions under the False Claims Act that allow anyone to report violations without repercussions | 105 | |
| 12853840895 | QMB | "Qualified Medicare beneficiary program"; a program that pays premiums, deductibles, and co-payments for Medicare low-income patients | 106 | |
| 12853840896 | RBRVS | "Resource based relative value system"; a basis for the physician fee schedule that applies work, overhead, and geographic adjustment in determining established fees | 107 | |
| 12853840897 | Re-bill | Also known as repeat claim; resubmission of a corrected claim | 108 | |
| 12853840898 | Right of subrogation | The substitution of one person for another in claiming a lawful right or debt | 109 | |
| 12853840899 | Scope of practice | The legal limits of licensure; the type of services that can be provided with given credentials | 110 | |
| 12853840900 | Secondary payer | The legally second billable insurance after the primary payer has sent payment, when more than one insurance policy is available. | 111 | |
| 12853840901 | Special report | A report that explains any unusual, variable, or infrequently performed procedures or services; should be sent with the claim for processing | 112 | |
| 12853840902 | Superbill | Also known as the charge slip, routing form, or encounter form; a documentation source for diagnostic, financial, and treatment information | 113 | |
| 12853840903 | TPA | 3rd party administrator; also known as a clearinghouse; a processing center for insurance claims | 114 | |
| 12853840904 | Title 19 | A social security act amendment establishing Medicaid | 115 | |
| 12853840905 | Title 21 | A social security act amendment establishing children's health insurance program (CHIP) | 116 | |
| 12853840906 | Turn around time | The time from claim to submission to payment | 117 | |
| 12853840907 | UCR | "Usual, customary, and reasonable fee"; the fee the provider usually charges for the service | 118 | |
| 12853840908 | Unbundling | Billing separately for procedures that are usually grouped or bundled together in a comprehensive code or codes; considered a fraudulent and/or illegal act | 119 | |
| 12853840909 | Unprocessable claim | A claim that can not be processed due to missing information | 120 | |
| 12853840910 | Upcoding | Choosing a higher level code than what is documented for the service provided; can be considered a fraudulent practice | 121 | |
| 12853840911 | UPIN | Unique provider identification number; specific number given to a provider by Medicare to identify the provider | 122 | |
| 12853840912 | Waiver | Also known as a rider; an addendum to an insurance policy that excludes certain conditions from coverage | 123 | |
| 12853840913 | Write off | The difference between the full fee and the allowed fee in a payer contract | 124 |
