Resource Library

The medical billing glossary.

Plain-English definitions for the billing, coding, and insurance terms you’ll run into — 151 and counting.

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Showing all 151 terms

A

Account number
The number assigned by your provider (hospital, physician, home care service, etc.) when medical services were provided.
Adjustment
The portion of your bill that your provider has agreed to write off.
Admission date (admit date)
The date admitted for treatment.
Admitting diagnosis
Words or phrases your doctor uses to describe your condition.
Advance beneficiary notice (ABN)
A notice your provider gives you before you are treated, informing you that Medicare will not pay for the treatment or service.
Allowed amount
Determined by your insurance to be the amount your provider is due for a particular service, usually less than billed and determined by pre-negotiated contracts or regulations.
Ambulatory surgery
Outpatient surgery or surgery that does not require an overnight hospital stay.
Amount not covered
What your insurance company does not pay, including deductibles, co-insurances and charges for non-covered services.
Ancillary service
The inpatient services you receive beyond room and board charges, such as laboratory tests, therapy, surgery, etc.
Appeal
A process by which you, your doctor or your hospital, can object to your health plan when you disagree with the health plan's decision to deny payment for your care.
Applied to deductible
A portion of your bill, as defined by your insurance company, that you owe your provider.
Assignment of benefits
An agreement you sign that allows your insurance to pay the provider directly.
Attending physician
The doctor who orders your treatment and who is responsible for your care.
Authorization number
A number stating that your treatment has been approved by your insurance plan. Also called a Certification Number, Prior Authorization Number or Treatment Authorization Number.

B

Beneficiary eligibility verification
A way providers can retrieve information about whether you have insurance coverage.
Benefit contract
The legal agreement between a health plan and you establishing the full range of benefits available through your healthcare plan.
Benefits
The extent to which your insurance coverage will pay for services provided to you.
Bill/invoice/statement
A printed summary of your medical bill.
Brand-name drug
Drugs made and sold by a major drug company that may or may not be listed on a formulary.

C

Centers for Medicare and Medicaid (CMS)
The federal agency that runs the Medicare program and works with states to run Medicaid programs.
Certification number
A number stating that your treatment has been approved by your insurance plan.
ChampVA
Insurance linked to military service that shares the cost of certain medically necessary procedures and supplies with eligible beneficiaries.
Claim
Your medical bill that is sent to an insurance company for payment.
Claim number
A number assigned by your insurance company to an individual claim.
Clinical research / clinical trial
Research conducted to evaluate the safety and/or effectiveness of a treatment, diagnostic procedure, preventive measure or similar medical intervention by testing on patients.
CMS 1500 form
The standard paper form used by healthcare professionals and suppliers to bill insurance companies.
Co-insurance
The amount you must pay after your insurance has paid its portion, according to your Benefit Contract.
Co-payment (Co-pay)
A predetermined, fixed fee that you pay at the time of service.
COBRA
A federal law that protects employees and their families by allowing them to keep existing health insurance for a specified time period.
Coding of claims
Translating clinical information from your medical record into numbers that insurance companies use to pay claims.
Commercial insurance plan
Typically an employer-sponsored or privately purchased insurance plan not maintained by government-run programs.
Consent for treatment
An agreement you sign that gives you permission to receive medical services or treatment from doctors or hospitals.
Coordination of benefits
How insurance companies work together when you have more than one insurance plan.
Covered benefit
Services that your insurance company pays for in full or in part.
Covered days
The days that your insurance company pays for in full or in part.
CPT (Current Procedural Terminology) code
A 5-digit numbering system that helps standardize professional and outpatient facility billing.

D

Date of bill
Bill preparation date, not the same as the date of service.
Date of service (DOS)
Treatment date.
Deductibles
The amount a patient pays before the insurance plan pays anything.
Diagnosis-related groups (DRGs)
A payment system used by many insurance companies for inpatient hospital bills that categorizes illnesses and procedures into groups.
Discharge hour
The time a patient is discharged from the hospital.
Discount
The dollar amount removed from your bill, usually because of a contract between your provider and insurance company.
Drugs / self-administered
Drugs that do not require administration from doctors or nurses and may not be covered by insurance as outpatient services.
Due from insurance
The amount your insurance company has agreed to pay.
Due from patient
The amount you owe.
Durable medical equipment (DME)
Medical equipment that can be used many times, or special equipment ordered by your doctor, usually for use at home.

E

Effective date
The date on which a Benefit Contract for coverage begins.
Eligibility
A determination of whether or not a person meets the requirements to participate in the plan.
Eligible payment amount
The medical services covered by an insurance company.
Emergency care
Care provided in a hospital Emergency Department.
Emergency department
The part of a hospital that treats patients with emergency or urgent medical problems.
Enrollee
A person who is covered by health insurance.
Estimated amount due
The amount the provider estimates you or your insurance company owes.
Estimated insurance
An estimate of payments from your insurance company.
Experimental or investigational treatments
A drug, device, diagnostic procedure, treatment or preventive measure not yet proven to be medically safe and/or effective.
Explanation of benefits (EOB)
A statement sent to you by your insurance after they process a claim, listing amounts billed, allowed, and paid.

F

Federal tax ID number
A number assigned by the federal government to doctors and hospitals for tax purposes.
Financial assistance program
No-cost or reduced rates for care provided to patients with demonstrated financial hardship.
Financial responsibility
The amount of your bill you have to pay.
Flexible spending account (FSA)
An employee benefit that allows a fixed amount of pre-tax wages to be set aside for qualified expenses.
Formulary
A list of preferred prescription medicines sorted into groups based on how much cost your health plan will pay.

G

Generic drug
Drugs with proven benefits that cost less because they are not made by major drug companies.
Guarantor
The person responsible to pay the bill, usually the patient unless incapacitated or a minor.

H

Health maintenance organization (HMO)
Health insurance plans requiring enrolled patients to receive all care from a specific group of providers except for emergency care.
Health plan
The type of health insurance you have, which may be group, individual, workers' compensation, or government-run.
Health savings account (HSA)
An account associated with a high deductible health plan allowing you to set aside pretax dollars for medical expenses.
Healthcare common procedure coding (HCPCS)
A five-digit numbering system that helps standardize professional and outpatient facility billing.
Healthcare provider
The party that provides medical services, such as hospitals, doctors or laboratories.
High deductible health plan (HDHP)
A health plan with an HSA providing medical coverage and a tax-advantaged way to save for medical expenses.
HIPAA
The federal Health Insurance Portability and Accountability Act setting standards for protecting health information privacy.
Home health agency
An agency that treats patients in their homes.
Hospice
The group offering inpatient, outpatient and home healthcare for terminally ill patients.
Hospital charge
The amount of money the hospital charges for a particular medical service or supply.
Hospital-based billing
Charges for services rendered in a hospital outpatient clinic or department.

I

ICD-10-CM
The official system of assigning codes to diagnoses and procedures for hospital utilization.
In-network
A group of doctors, hospitals and other healthcare providers preferred and contracted with your insurance company.
Incremental nursing charge
The charges for nursing services added to basic room and board charges.
Individual insurance
Health insurance purchased by an individual, not as part of a group plan.
Insurance waivers
The services excluded from your insurance policy, such as cancer care or pre-existing conditions.
Insured group name
The name of the group or insurance plan that insures you, usually an employer.
Insured group number
A number your insurance company uses to identify the group under which you are insured.
Insured's name (beneficiary)
The name of the insured person, also referred to as the member.
Intensive care
The medical or surgical care unit in a hospital providing care for patients needing more care than general units.

L

Liability
The person or persons liable or under obligation for the bill.
Lifetime maximum coverage
Coverage limits that health plans can place on certain non-essential health benefits annually or for a lifetime.
Long-term care
The care received in a nursing home.

M

Managed care
A type of insurance plan requiring patients to see providers with contracts except in emergencies.
Medicaid
A jointly funded federal and state health insurance plan for low income adults, pregnant women, children and people with disabilities.
Medical record number
The number assigned by your doctor or hospital identifying your individual medical record.
Medicare
A federal health insurance program for people 65 or older, certain younger people with disabilities, and people with end-stage renal disease.
Medicare Advantage
A type of Medicare health plan offering Part A and Part B benefits plus additional benefits not in Original Medicare.
Medicare assignment
Providers who accept Medicare patients and agree not to charge more than Medicare approved.
Medicare number
A unique number assigned to each person covered under Medicare used for billing and eligibility.
Medicare Part A
Hospital Insurance helping pay for inpatient care in hospitals, hospices, and some skilled nursing costs.
Medicare Part B
Assists with paying for doctor services, outpatient care and other medical services not covered by Part A.
Medicare summary notice (MSN)
A statement Medicare sends after processing a claim, listing billed, allowed, and paid amounts.
Medigap
Policies supplementing Medicare coverage that usually pay Medicare co-pays and deductibles.

N

Network
A group of doctors, hospitals, pharmacies and other healthcare experts hired by a health plan for members.
Non-covered charges
Charges for medical services denied or excluded by your insurance that you may be billed for.
Non-participating provider
A doctor, hospital or other healthcare provider not part of an insurance plan network.

O

Observation
A hospital outpatient service ordered when a physician isn't sure you need inpatient care but needs monitoring.
Out-of-network provider
A doctor or other healthcare provider not part of an insurance plan or hospital network.
Out-of-pocket costs
Costs the patient is responsible for because insurance does not cover them.
Out-of-pocket maximum
The most money you will pay before insurance covers all costs for the remainder of the calendar year.
Over-the-counter drug
Drugs that do not require a prescription and can be bought at pharmacies or drugstores.

P

Paid to provider
The amount the insurance company pays to your medical provider.
Paid to you
The amount the insurance company pays to you or your guarantor.
Participating provider
A doctor or hospital accepting payment from your insurance as payment in full minus deductibles and copays.
Patient amount due
The amount your provider charges you for services received.
Physician practice
A group of doctors, nurses and physician assistants who work together.
Physician practice management
Non-physician staff hired to manage the business aspect of a physician practice.
Point of service (POS)
A type of health plan allowing members to choose participating or non-participating network providers.
Policy number
A number your insurance company gives you to identify your contract.
Power of attorney
A legal document allowing you to appoint another person to act on your behalf and make decisions.
Pre-admission approval or certification
An agreement by your insurance company and you or your provider to pay their portion of treatment.
Pre-existing condition
A medical condition for which the patient received treatment before enrolling in a new insurance plan.
Preferred provider organization (PPO)
A healthcare organization covering more costs if patients use services on their preferred provider list.
Prepayments
Money you pay before receiving medical care, also referred to as preadmission deposits.
Primary care physician (PCP)
A doctor whose practice involves internal medicine, family, general practice or pediatrics.
Primary insurance company
The insurance responsible for paying your claim first before secondary insurance.
Prior authorization number
A number stating your treatment has been approved by your insurance plan.
Procedure code
A code given to medical and surgical procedures and treatments.
Prospective payment system (PPS)
A method of reimbursement where Medicare payment is based on a predetermined fixed amount.
Provider
A hospital or physician who provides medical care to the patient.
Provider contract discount
A part of your bill your provider must write off because of billing agreements with insurance.

R

Referral
Approval needed for care beyond that provided by your primary care doctor or hospital.
Release of information
A signed statement allowing providers to release medical information so insurance companies can pay claims.
Remittance advice
The explanation the hospital receives from your insurance company after medical services are processed.
Responsible party
The person responsible for paying your hospital bill, usually referred to as the guarantor.
Revenue code
A billing code used to name a specific room, service or billing sum.

S

Same-day surgery
A surgery performed as an outpatient service.
Secondary insurance
For people with more than one insurance plan, the secondary policy may cover expenses after primary insurance pays.
Self-insured health plan
A group health plan where the employer assumes the risk for providing healthcare benefits to employees.
Self-pay
A person who pays out-of-pocket for healthcare services in the absence of insurance.
Service area
A geographic area where insurance plans enroll members and HMOs serve providers and hospitals.
Skilled nursing facility
An inpatient facility providing nursing care or other therapy for patients not requiring acute hospital care.
Social security disability insurance (SSDI)
An income assistance program for those with disabilities lasting at least one year or expected to result in death.
Source of admission
The source of your admission, whether referral, transfer or through the emergency room.
Specialist
A doctor who specializes in treating certain parts of the body or specific medical conditions.
Statement covers period
The dates your service or treatment begin and end.
Submitter ID
The identification number doctors and hospitals use when billing electronically.
Supplemental insurance company
An additional insurance policy handling deductible and co-insurance reimbursement claims.
Supplemental security income (SSI)
A disability income program for disabled people who haven't worked enough to qualify for SSDI.

T

Third-party payer
An organization other than the patient or healthcare provider involved in paying healthcare claims.
Treatment authorization number
A number stating your treatment has been approved by your insurance plan.
Tricare
A health care program for active duty and retired uniformed service members and their families.
Type of admission
The reason for your admission, such as emergency, urgent or elective.

U

UB-04 claim form
The standard claim form used by institutional providers like hospitals to bill insurance companies.
Units of service
Measures of medical services a patient received, such as hospital days, blood pints, or lab tests.
Usual, customary and reasonable (UCR)
A charge considered usual and customary if it falls within the range charged by other providers in the same geographic area.

W

Waiting period
The amount of time members must wait after enrolling in an insurance plan before eligibility for certain benefits.

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