Glossary of Billing Terms

Advance Beneficiary Notice (ABN) - A notice that the hospital should give a Medicare beneficiary when providing a service for which Medicare is expected to deny payment. If you do not get an ABN before you receive services and Medicare does not pay for it, then you probably do not have to pay for it. If the hospital does give you an ABN and you sign that you understand the service may not be covered by Medicare then you will have to pay the hospital for the services provided.

Ambulatory Care - Types of health services that are provided on an outpatient basis.

Ancillary Services - Services provided by the hospital such as X-rays and laboratory tests.

Appeal - A complaint you make if you disagree with a decision made by your insurance company, to deny a request for services or payment for services you have already received. 

Approved Amount - The fee Medicare or an insurance company sets as reasonable for a covered medical service. It may be less than the actual amount charged by the hospital.

Assignment - The hospital agrees to accept the approved amount as full payment. You will still pay your share of the bill which could include deductibles and co-insurance.

Beneficiary - The person who is eligible for or receiving benefits under an insurance plan.

Benefits - Medical services for which your insurance plan will pay.

Centers for Medicare & Medicaid Services (CMS) - The federal agency that runs the Medicare program. CMS also works in partnership with states to administer the Medicaid program.

Claim - A request to the insurance company to pay for services you have received.  

Co-Insurance - The percentage of an insurance payment that you may have to pay after you pay any plan deductibles. For example, after your deductible has been satisfied your insurance carrier will usually pay the remainder at a percentage such as 80 percent. The remaining 20 percent will be your responsibility.

Coordination of Benefits - Process for determining the responsibilities of two or more health plans that have some responsibility for the same covered medical services.

Covered Benefit - A service that is included in your health plan.

Deductible - The amount you must pay before your insurance begins to pay. Deductibles are common in many policies and are usually based on the calendar year.

Diagnosis - The name for the health problem that has been determined by examination and analysis.

Discharge Planning - A process used to decide what a patient needs when he or she is moved from one level of care to another. For example, moving a patient from the hospital to either skilled care or a nursing home. This is coordinated by a social worker or other healthcare professionals.

Durable Power of Attorney - A legal document that enables you to designate another person to act on your behalf in the event you become unable to make decisions on your own.

Emergency Care - Care given for a medical emergency when you believe that your health is in serious danger.

Explanation of Benefits - An explanation sent to the policyholder from your insurance plan that explains services provided, amount billed and payment made. This would include insurance payment, co-payments, co-insurance and deductibles.

Group Health Plan (GHP) - A group health plan that is from an employer and gives health coverage to employees and their families.

Healthcare Provider - A person or a place that is trained and licensed to give healthcare.  Doctors, nurses and hospitals are examples.

Health Insurance Portability & Accountability Act (HIPAA) - A law passed in 1996 that expands your healthcare coverage if you have lost your job or if you move from one job to another. It also provides easier portability of medical information by standardizing electronic transactions and protects your privacy.

Health Maintenance Organizations (HMO) - A type of managed care plan where healthcare is provided by plan members for a fixed, prepaid premium.

Liability Insurance - Insurance that protects against claims which result in injury to someone or damage to property.

Maximum Out of Pocket Expense - The maximum amount you will be required to pay during a specific period.

Medicaid - A joint federal and state program that helps with medical costs for people with low incomes and limited resources. 

Medical Power of Attorney - A document that lets you appoint someone to make decisions about your medical care.

Medicare – A federal program that pays for healthcare provided to eligible people, 65 years of age or older, and to qualified disabled people. Medicare is a four-part program.

Medicare Part A is hospital insurance and helps cover inpatient care in hospitals, skilled nursing, hospice and home health.

Medical Part B is medical insurance that helps cover doctor services, outpatient care and home healthcare. It also pays for some preventative services.

Medicare Part C is Medicare Advantage Plans such as HMO or PPO.

Medical Part D is Medicare Prescription Drug Coverage. 

Network - Selected providers such as hospitals and doctors that an HMO, PPO or managed care plan has selected to provide care for its members.

No-Fault Insurance - Insurance that pays for healthcare services resulting from injury to you or damage to your property, regardless of who is at fault.

Out of Network - Services provided outside of your plan’s contracted network of providers. In most cases, your out of pocket expenses will be higher.

Outpatient Prospective Payment System (OPPS) - The way that Medicare pays for most outpatient hospital services.

Preferred Provider Organization (PPO) - A managed care plan in which you use doctors, hospitals and providers that belong to the plan’s network.

Primary Payer - An insurance plan that pays first on a claim for medical care.

Provider - A doctor, hospital or healthcare professional.

Referral - A recommendation from your primary care physician for you to see a specialist or get certain services. With some plans, if you do not get a referral first your plan may not pay for the services provided.

Secondary Payer - An insurance plan that pays second on a claim for medical care.

Subscriber - The policyholder of a health plan. An individual or his or her employer pays the premium of the health plan.