Healthcare Glossary Terms & Achronyms
835 - ANSI X12 835 Version 5020 ANSI 835 is the American National Standards Institutes Health Care Claims Payment and Remittances Advice Format. The format handles health care claims in a way that follows HIPAA regulations. 835 replaces existing formats (both electronic and paper) for sending "Explanation of Benefits" (EOB) forms. EOBs are filled with information about a claims payment and the amounts owed by each party involved in the claim. The ANSI 835 consists of the programming language the transactions are created and sent in.
Advance Beneficiary Notice (ABN) ABN billing rules permit Providers and other Part B care providers to bill beneficiaries directly when Medicare will not cover services for lack of medical necessity.
Allowed Expenses The maximum amount a plan pays for a covered service. See Usual and Customary Charges.
Ambulatory Care Medical services provided on an outpatient (non-hospitalized) basis.
ANSI - American National Standards Institute ANSI is a private non-profit organization that oversees the development of voluntary consensus standards for products, services, processes, systems, and personnel in the United States. It's primary task is to determine hardware and software standards.
AOB - Assignment of Benefits An authorization directing an insurer to make payment directly to a provider of benefits, such as a provider or dentist, rather than to the insured.
APC - Ambulatory Patient Classifications A structure for classifying outpatient services and procedures for purposes of payment.
Assignment& Authorization A form signed by the patient showing insurance plans assigned and their billing priority. This form allows the hospital to bill insurances on the patient’s behalf and receive payment directly from the payer. Signature on the form also authorizes the release of medical information to MidState Medical Center or Connecticut Children’s Medical Center, in the event the patient is transferred to one of these facilities.
Benefits These are medical services for which your insurance plan will pay, in full or in part.
Beneficiary Someone who is eligible for or receiving benefits under an insurance policy or plan.
Capitated (Capitated Claim) A payment method for health care services. The provider, hospital, or other health care provider is paid a contracted rate for each member assigned, referred to as "per-member-per-month" rate, regardless of the number or nature of services provided. The contractual rates are usually adjusted for age, gender, illness, and regional differences.
Claim A notice to the insurance company that a person received care covered by the plan. A claim is also a request for payment.
Coding How provider's services are identified and defined.
Co-Insurance A type of cost sharing where the beneficiary and insurance provider share payment of the approved charge for covered services in a specified ratio after payment of the deductible by the insured. For example, for Medicare Providers' services, the beneficiary pays co-insurance of 20 percent of allowed charges.
Consolidated Omnibus Budget Reconciliation Act (COBRA) A federal law that requires employers to offer continued health insurance coverage to certain employees and their beneficiaries whose group health insurance coverage has been terminated. Applies to employers with 20 or more eligible employees. Typically, COBRA makes continued coverage available for up to 18 or 36 months. COBRA enrollees may be required to pay 100 percent of the premium, plus an additional 2 percent.
Coordinated Coverage Integrating benefits payable under more than one health insurance (for example, Medicare and retiree health benefits). Coordinated coverage is typically arranged so the insured benefits from all sources not exceeding 100 percent of allowable medical expenses. Coordinated coverage may require beneficiaries to pay some deductible or co-insurance.
COB Coordination of Benefits A provision that applies when a person is covered under more
than one group medical program. (See "Coordinated Coverage" above.)
Co-Payment It's a set fee the member pays to providers at the time services are provided. Co-pays are applied to emergency room visits, hospital admissions, office visits, etc. The cost is usually
minimal. The patient should be aware of the co-payment amounts prior to services being rendered.
Coverage What services the health plan does and does not pay for.
Covered Expenses What the insurance company will consider paying for as defined in the contract. For example, under some plans generic prescriptions are covered expenses while brand name prescriptions are not.
CPT - Current Procedural Terminology A code set maintained by the AMA through the CPT Editorial Panel. The CPT code set describes medical, surgical, and diagnostic services and to communicate uniform information about medical services and procedures among Providers, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. The current version is the CPT 2011.
DOS - Date of Service The date(s) healthcare services were provided to the beneficiary.
Deductible A portion of the covered expenses (typically $100, $200 or $500) that an insured individual must pay before insurance coverage with co-insurance goes into effect. Deductibles are standard in many policies, and are usually based on a calendar year.
DRGs - Diagnosis-Related Groups The hospital classification and reimbursement system that groups patients by diagnosis, surgical procedures, age, sex and presence of complications. This is a
financing mechanism used to reimburse hospital and selected other providers for services rendered.
DCI - Duplicate Coverage Inquiry A request to an insurance company or group medical plan by
another insurance company or medical plan to find out whether other coverage exists (see coordinated Coverage).
DME - Durable Medical Equipment Medical equipment which: can withstand repeated use; is not
disposable; is used to serve a medical purpose; is generally not useful to a person in the absence of
sickness or injury, and is appropriate for use in the home. Examples include hospital beds, wheelchairs and oxygen equipment.
ERA – Electronic Remittance Advice Electronic Remittance Advice is an electronic transaction that
enables healthcare providers to receive claim payment information electronically. This replaces the
paper Explanation of Benefits (EOB). ERA files are transmitted to healthcare providers in the HIPAA mandated ASC X12 835 5010 A1 format.
ERISA - Employee Retirement Income Security Act of 1974 This law mandates reporting, disclosure of grievance and appeals requirements and financial standards for group life and health. Self-insured plans are regulated by this law.
Enrollee The person who is covered by health insurance.
EPO - Exclusive Provider Organization Arrangement consisting of a group of providers who have a contract with an insurer, employer, third party administrator or other sponsoring group. Criteria for
provider participation may be the same of those in PPOs but have a more restrictive provider selection and credentialing process.
Experimental Procedures Any healthcare services, that are determined by the insurance plan to be either; not generally accepted by informed healthcare professionals in the United States as effective in treating the condition, illness or diagnosis for which their use is proposed; or not proven by scientific evidence to be effective in treating the condition for which it is proposed.
EOB - Explanation of Benefits The coverage statement sent to covered persons listing services
rendered, amount billed and paymentmade. This normally would include any amounts due from the
patient, as described in "Beneficiary Liability," "Co-insurance," "Deductible" and "Co-payment" all
Health Care Provider An individual or institution that provides medical services (e.g. a provider, hospital or laboratory). This term should not be confused with an insurance company that "provides" insurance.
Health Insurance Coverage that provides for the payment of benefits as a result of sickness or injury. Includes insurance for losses from accident, medical expense, disability, or
accidental death and dismemberment.
HIPAA - Health Insurance Portability and Accountability Act Federal legislation to provide easier portability of medical information by standardizing electronic transaction and code sets, and enacting additional patient privacy provisions.
HMO - Health Maintenance Organization An entity that provides, offers or arranges for coverage of designated health services needed by plan members for a fixed, prepaid premium.
Hospital Inpatient Prospective Payment System (PPS) Medicare's method of paying acute care hospitals for inpatient care. Prospective per-case payment rates are set at a level intended to cover operating costs for treating a typical inpatient in a given DRG.
ICD-10-CM - International Classification of Diseases, (Clinical Modification) A listing of diagnosis and identifying codes used by Providers and hospitals for reporting diagnoses and
procedures of health plan enrollees.
JCAHO (JACO) Joint Commission on Accreditation of Healthcare Organizations
JCAHO is an organization made up of individuals from the private medical sector to develop and maintain standards of quality in medical facilities in the United States. The JCAHO has no official connection to United States government regulatory agencies, and has no legal enforcement power; however, since many medical facilities rely on JCAHO accreditation procedures to indicate to the public that their particular institution meets quality standards, JCAHO and its policies has taken on a real importance in the healthcare industry.
Maximum Out of Pocket The most money you can expect to pay for covered expenses. The
maximum limit varies from plan to plan. Once the maximum out-of-pocket has been met, the health
plan will pay 100% of certain covered expenses.
Medicaid A jointly-funded, Federal-State health insurance program for certain low-income and needy people. It covers approximately 36 million individuals including children, the aged, blind, and/or disabled, and people who are eligible to receive federally assisted income
Medicare A federal health benefit program for people over 65 and disabled that covers 35 million Americans - or about 14% of the population - for an annual cost of over $120 billion. Medicare pays for 25% of all hospital care and 23% of all provider services.
Medicare Benefits Notice A notice you get after your doctor files a claim for Part A
services in the Original Medicare Plan. It says what the provider billed for, the Medicare-approved amount, how much Medicare paid, and what you must pay. You might also get an Explanation of Medicare Benefits (EOMB) for Part B services or a Medicare Summary Notice (MSN).
Medicare Coverage Made up of two parts: Hospital Insurance (Part A) and Medical Insurance (Part B). (See Medicare Part A (Hospital Insurance); Medicare Part B (Medical Insurance).)
Medicare Part A (Hospital Insurance) Hospital insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care and some home healthcare.
Medicare Part B (Medical Insurance) The part of Medicare that covers doctors' services and
outpatient hospital care. It also covers other medical services that Part A does not cover, like physical and occupational therapy.
Medicare Secondary Payer A statutory requirement that private insurers providing general
health insurance coverage to Medicare beneficiaries pay beneficiary claims as primary payers.
Medicare Supplement Policy (Medsupp) The insurer will pay a policyholder's Medicare co-insurance, deductible and co-payments for Medicare Part A and B and may provide additional supplement benefits according to the supplement policy selected.
Medigap Insurance Privately purchased individual or group health insurance policies designed to supplement Medicare coverage. Benefits may include payment of Medicare deductibles, co-insurance and balance bills, as well as payment for services not covered by Medicare.
Medigap Plan Purchased by Medicare enrollees to cover co-payments, deductibles and healthcare goods or services not paid for by Medicare. Also known as a Medicare supplements policy.
Medigap Policy A privately purchased insurance policy that supplements Medicare coverage.
Network Providers, hospitals, and other healthcare providers that an HMO, PPO or other managed care network has selected to provide care for its members.
Non-Participating Provider (Non-par) Also known as out-of-network provider. A healthcare
provider who has not contracted with the carrier of a health plan to be a participating provider of
Open Enrollment A specified period of time in which employees may change insurance plans and medical groups offered by their employer and have the new insurance effective at a later date.
Out of Network (OON) Coverage for treatment obtained from a non-participating provider. typically, it requires payment of a deductible and higher co-payments and co-insurance than for
treatment from a participating provider. Insurer may also deny entire bill.
Out-of-Pocket-Costs/Expenses (OOPs) The portion of payments for covered health services required to be paid by the patient, including copayments, co-insurance and deductible. (See "Beneficiary Liability," "Co-insurance," "Deductible" and "Co-payment" above.)
Participating Provider A provider who has contracted with the health plan to deliver medical services to covered persons. The provider may be a hospital, pharmacy or other facility or a
provider who has contractually accepted the terms and conditions as set forth by the health plan.
PAC - Pre-Admission Certification A review of the need for inpatient hospital care, completed
before the actual admission.
Part A Medicare Medical Hospital Insurance (HI) under part A of title XVIII of Social Security Act, which covers patients for inpatient hospital, home health, hospice and limited skilled nursing facility services. Beneficiaries are responsible for deductibles and co-payments.
Part B Medicare Medicare Supplement Medical Insurance (SMI) under Part B of Title XVII of the Social Security Act, which covers Medicare beneficiaries for provider services, medical supplies and other outpatient treatment. Beneficiaries are responsible for monthly premiums, co-payments, deductibles and balance billing.
POS - Point-of-Service Plan Managed care product that offers enrollees a choice among
options when they need medical services, rather than when they enroll in the plan. Enrollees may use
providers outside the managed care network, but usually at higher cost. (This should not be confused with POS as used in retail pharmacy, where it stands for point of sale.)
Preauthorization An insurance plan requirement in which you or your primary care provider need to notify your insurance company in advance about certain medical procedures (like outpatient surgery) in order for those procedures to be considered a covered expense.
Pre-certification Authorization given by a health plan for a Member to obtain services from a healthcare provider, most commonly required for hospital services. Members should refer to
their insurance identification card or call their health plan to obtain information regarding pre-certification requirements.
PEC - Pre-existing Condition Any medical condition that has been diagnosed or treated within
a specified period immediately preceding the covered person's effective date of coverage. Pre-existing conditions may not be covered for some specified amount of time as defined in the certificate
of coverage (usually six to 12 months). Individuals can be required to satisfy a pre-existing waiting
period only once, so long as they maintain continuous group health plan coverage with one or more
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.
PPO - Preferred Provider Organization A program that establishes contracts with providers of medical care. Providers under such contracts are referred to as a preferred provider. Usually, the benefit contract provides significantly better benefits and lower member costs for services received from preferred providers, thus encouraging covered persons to use these providers.
Premium Amount paid periodically to purchase health insurance benefits.
PCN - Primary Care Network A group of primary care Providers who have joined together to
share the risk of providing care to their patients who are covered by a given health plan.
PCP - Primary Care Provider A provider, the majority of whose practice is devoted to internal medicine, family/general practice and pediatrics. An obstetrician/gynecologist sometimes is considered
a primary care provider, depending on coverage.
Reasonable Charge A fee is considered "Reasonable" if it is both usual and customary or if it is justified because there is a complex problem involved.
Referral Approval or consent by a primary care provider for patient referral to ancillary services and
Secondary Payer An insurance policy, plan, or program that pays second on a claim for medical care. This could be Medicare, Medicaid, or other health insurance depending on the situation. For Commercial or Managed payers, if you have additional coverage through your spouse, then coverage through their insurance will be considered your secondary. For children covered under two insurance plans, primary coverage will be determined by the Subscriber (Mom or Dad) whose month of birth
is closest to the beginning of the year. This is also known as the Birthday Rule.
Skilled Nursing Facility A facility (which meets specific regulatory certification requirements) which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.
Specialist A provider who specializes in a specific area of medicine, such as cardiology, oncology, urology, etc. Most HMO's require members to obtain a Referral from their Primary Care Provider before setting an appointment to see a Specialist.
Sub-Acute Care Usually described as a comprehensive inpatient program for those who have experienced a serious illness, injury or disease, but who do not require intensive hospital services. The range of services considered sub-acute can include infusion therapy, respiratory care, cardiac services, wound care, rehabilitation services, post-operative recovery programs for knee and hip replacements, cancer, stroke and AIDS care.
Subscriber The person responsible for payment of premiums or whose employment is the basis for eligibility for membership in an HMO or other health plan.
Supplementary Medical Insurance The Medicare program that pays for a portion of the costs of
Providers' services, outpatient hospital services, and other related medical and health services for
voluntarily insured aged and disabled individuals. Also known as Part B.
TPA - Third Party Administrator An independent person or corporate entity (third party) that
administers group benefits, claims and administration for a self-insured company or group.
UCR - Usual, Customary and Reasonable A term used to refer to the commonly charged or prevailing fees for health services within a geographic area.
Utilization Review (UR) Programs designed to reduce unnecessary medical services, both
inpatient and outpatient. Utilization reviews may be prospective, retrospective, concurrent, or in
relation to discharge planning.