Key Terms

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Adjustment
The portion of your bill that your provider has agreed not to charge you.

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. The notice is provided so you may decide whether to have the treatment and how to pay for it.

Ambulatory Payment Classifications (APC)
A Medicare payment system that classifies outpatient services so Medicare can pay all hospitals the same amount.

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 services you receive beyond room and board charges, such as laboratory tests, therapy and surgery.

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.

Awaiting Insurance
The amount pending with your insurance company for payment. Depending on your insurance benefits, this amount may or may not be paid in full by your insurance company.

Beneficiary
A person covered by health insurance.

Beneficiary Eligibility Verification
A way providers retrieve information about whether you have insurance coverage.

Benefit
The amount your insurance company pays for medical services.

Bill/Invoice/Statement
A printed summary of your medical bill.

Cardiology Charges
The charges for procedures performed to test the heart, such as stress testing and catherization.

Centers for Medicare and You Medicaid Services (CMS)
The federal agency that runs the Medicare program. In addition, CMS works with states to run the Medicaid programs.

Champus
Insurance linked to military service, also known as TriCare.

Charity Care
Free or reduced rates for care provided to patients with financial hardship.

Claim
Your medical bill that is sent to an insurance company for payment.

CMS-1500
A medical insurance claim form used for physician professional fees. Formerly known as HCFA-1500. See UB-04.

COBRA Insurance
Health insurance that you can buy when you are unemployed for a certain period of time.

Coding of Claims
Translating diagnoses and procedures from your medical record into numbers that insurance companies use to pay claims.

Coinsurance
The percentage of eligible medical expenses that a health plan requires a member to pay after the member has met the deductible and before the member has reached the out-of-pocket maximum.

Coinsurance Days (Medicare)
Hospital inpatient Medicare coverage from day 61 to day 90 of continuous hospitalization. Patients on Medicare are responsible for paying for part of these days. After day 90 you enter into your “Lifetime Reserve Days.”

Consent (Conditions of Service)
An agreement you sign that gives your permission to receive medical services or treatment from doctors or hospitals.

Coordination of Benefits (COB)
A way to decide which insurance company is responsible for payment, if you have more than one insurance plan.

Co-payment
A specified dollar amount that a member must pay up front (out-of-pocket) for a specified service at the time the service is rendered.

Covered Service
A health care service that is covered by an insurance plan, and for which the plan agrees to pay a certain benefit amount or percentage.

CPT Procedure Code
A code used by medical offices and insurance companies to identify a specific medical service or procedure.

Date of Service (DOS)
Treatment date.

Deductible
The amount you must pay for covered medical services before your insurance company starts to pay benefits. Usually a new deductible needs to be met each calendar year.

Diagnosis Code (ICD9)
A code used at the time of billing to describe your illness.

Diagnosis-Related Groups (DRGs)
A payment system for hospital bills. This system categorizes illnesses and medical procedures into groups. Hospitals are paid a fixed amount for each admission.

Discount
The dollar amount removed from your bill, usually because of a contract between your provider and your insurance company.

Drugs/Self Administered
Drugs that do not require administration from doctors or nurses. Your insurance plan may not cover these when provided during an outpatient visit.

Due from You
The amount you owe.

Durable Medical Equipment (DME)
The medical equipment that can be used many times, or special equipment ordered by your doctor, usually for use at home. Also referred to as “home medical equipment.”

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

Emergency Department
The part of a hospital that treats patients with emergency or urgent medical problems.

Explanation of Benefits (EOB)
The notice you receive from your insurance company after your bill has been processed or paid. The notice tells you the amount the provider billed, the amount paid by your insurance and what you have to pay. See Medicare Summary Notice.

Family Billing
Providence statements usually include all family members. If you prefer separate bills for each adult patient, please contact us and tell us you would like to have statements listed by each adult patient instead of family billing.

Federal Tax ID Number
A number assigned by the federal government to doctors and hospitals for tax purposes.

Financial Assistance
We may be able to help uninsured patients who have limited incomes, live within the communities we serve and are unable to pay their Providence medical bills. To be considered for assistance, a financial assistance form should be completed. Financial assistance forms can be picked up at any Providence hospital, printed from the Providence Web site or mailed upon request.

Fiscal Intermediary (FI)
A company hired by Medicare to pay Medicare claims.

HCPCS Codes
A coding system used to describe what treatment or services your doctor or provider gave to you.

Health Care Advance Directive
A written document that describes how you want medical decisions to be made if you lose the ability to make decisions for yourself. A health care advance directive may include a Living Will and a Durable Power of Attorney for health care decisions.

Health Care Provider
The party that provides medical services, such as hospitals, doctors or laboratories.

Health Maintenance Organization (HMO)
An insurance plan that pays for preventive and other medical services provided by a specific group of participating providers.

HIPAA
Health Insurance Portability and Accountability Act. This federal act sets standards for protecting the privacy of your health information.

Home Health Agency
An agency that treats patients in their homes.

Hospice
The group that offers inpatient, outpatient and home health care for terminally ill patients.

Hospital Charge
The amount of money the hospital charges for a particular medical service or supply.

Incremental Nursing Charge
The charges for nursing services added to basic room and board charges.

In-Network Provider
A doctor or other health care provider who is a part of an insurance plan, doctor or hospital network. See Network.

Inpatient (IP)
A patient is an inpatient when the physician orders an “inpatient admission.” A patient is an outpatient when the physician orders an “outpatient admission.” Depending upon the patient's specific situation, along with physician's order, a patient can spend the night in the hospital and still be classified as an outpatient. See Outpatient.

Insurance Adjustment
A part of your bill that your provider must write-off because of billing agreements with your insurance company.

Insurance Waivers
The services excluded from your insurance policy, such as cancer care or obstetric/gynecologic 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 that your insurance company uses to identify the group under which you are insured.

Insured's Name (Beneficiary)
The name of the insured person, who is also referred to as the member.

Intensive Care
The medical or surgical care unit in a hospital that provides care for patients who need more care than a general medical or surgical unit can provide.

Lifetime Reserve Days (Medicare)
Under Medicare, you have a lifetime reserve of 60 more days of inpatient services after you use the first 90 benefit days. You must pay a fixed amount for each day of service.

Long-Term Care
The care received in a nursing home. Medicare does not pay for long-term care unless you need skilled nursing or special rehabilitation.

Managed Care
An insurance plan that requires patients only see providers (doctors and hospitals) that have a contract with the managed care company. The exception is in the case of medical emergencies or urgent care, if you are out of the plan's service area.

Medicaid
A state administered, federal and state funded insurance plan for low income people who have limited or no insurance.

Medical Record Number
The number assigned by your doctor or hospital that identifies your individual medical record.

Medicare
A health insurance program for people age 65 and older. Medicare covers some people under age 65 who have disabilities or end-stage renal disease (ESRD).

Medicare Advantage Plan
A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. Medicare Advantage Plans are HMOs, PPOs or private fee-for-service plans. If you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plans, and are not paid for under Original Medicare.

Medicare Approved
Medical services normally paid for by Medicare.

Medicare Assignment
Providers who have accepted Medicare patients and agreed not to charge them more than Medicare has approved.

Medicare Number
A number and an ID card is assigned to each person covered under Medicare and You for identification to providers.

Medicare Paid
The amount of your bill paid by Medicare.

Medicare Paid Provider
The amount of your bill Medicare paid to your provider.

Medicare Part A
Usually referred to as hospital insurance, it helps pay for inpatient care in hospitals and hospices, as well as some skilled nursing costs.

Medicare Part B
Medicare coverage that assists with paying for doctor services, outpatient care and other medical services not paid for by Medicare part A.

Medicare Part D
Medicare coverage that assists with paying for prescription drugs, and is available to anyone eligible for Medicare part A and/or part B.

Medicare Summary Notice (MSN)
The notice provided by Medicare after receiving services from your provider. It tells you what was billed to Medicare, Medicare's approved payment, the amount Medicare paid and the amount you owe. Also called an Explanation of Benefits (EOB).

Medicare Supplemental Insurance
An additional insurance policy that handles claims for deductible and co-insurance reimbursement for Medicare-covered services.

Medigap
Medicare Supplement Insurance that pays for some services not covered by Medicare A or B, including deductible and co-insurance amounts.

Network
A group of doctors, hospitals, pharmacies and other health care experts hired by a health plan to take care of its members.

Non-Covered Charges
The charges for medical services denied or excluded by your insurance. You may be billed for these charges.

Non-Participating Provider
A doctor, hospital or other health care provider that is not part of an insurance plan, doctor or hospital network.

Observation
The type of service used by doctors and hospitals to decide whether you need inpatient hospital care or whether you can recover at home or in an outpatient area.

Out-of-Network Provider
A doctor or other health care provider who is not part of an insurance plan, doctor or hospital network. See Non-Participating Provider.

Out-of-Pocket Costs
The costs the patient is responsible for because Medicare or other insurance does not cover them.

Out-of-Pocket Maximum
A dollar amount set by a health plan that limits the total amount a member will have to pay out of his or her own pocket for covered health care services during a particular period (often one year).

Outpatient (OP)
A service you receive in one day or overnight at a hospital. See Inpatient.

Over-the-Counter Drug
Drugs that do not require a prescription. They can be bought at a pharmacy or drug store and be dispensed to patients, while at the hospital or doctors office.

Participating Provider
A doctor or hospital that agrees to accept your insurance payment for covered services as payment in full, minus your deductibles, co-pays and co-insurance amounts.

Payment Arrangements
A formal payment plan set up between a patient and Providence when payment cannot be made in full.

Payor
A third-party entity (commercial or government insurance carrier) that pays medical claims.

Per Diem
The amount charged or paid by the day.

Physician Practice
A group of doctors, nurses and physician assistants who work together.

Point-of-Service Plan (POS)
An insurance plan that allows you to choose doctors and hospitals without having to first get a referral from your primary care doctor.

Policy Number
A number your insurance company gives you to identify your contract.

Pre-Admission Approval or Certification
An agreement made by your insurance company and you or your provider, to pay their portion of your medical treatment. Providers ask your insurance company for this approval before providing your medical treatment.

Pre-Existing Condition
A health condition or a medical problem acknowledged by your health plan before you receive insurance. Some health plans may not pay for health conditions you had prior to becoming a member.

Preferred Provider Organization (PPO)
An insurance plan in which you use doctors, hospitals and providers that belong to the network. You can use doctors, hospitals and providers outside of the network for an additional cost.

Prepayments
The money you pay before receiving medical care; also referred to as preadmission deposits.

Primary Care Physician (PCP)
A doctor whose practice is devoted to internal medicine, family and general practice or pediatrics. Some insurance companies consider obstetricians or gynecologists primary care physicians.

Primary Insurance Company
The insurance company responsible for paying your claim first. If you have another insurance company, it is referred to as the Secondary Insurance Company.

Prior Authorization/Precertification
A formal approval obtained from the insurance company prior to delivery of medical services. Many insurance companies require prior authorization or precertification for specific medical services.

Provider
A hospital or physician who provides medical care to the patient.

Reasonable and Customary (R & C)
The costs for medical services that insurers believe are appropriate throughout a geographic area or community. Also referred to as Usual and Customary (U & C).

Reference Number
This is your “family billing” number. It is the number for the person responsible for paying the bill if a balance is due.

Referral
Approval needed for care beyond that provided by your primary care doctor or hospital. For example, managed care plans (HMOs) usually require referral forms from your primary care doctor to see a specialist or for special procedures.

Release of Information
A signed statement from patients or guarantors that allows providers to release medical information so that insurance companies can pay claims.

Responsible Party/Guarantor
The person responsible to pay the bill.

Secondary Insurance
Insurance that may pay some charges not paid by your primary insurance company. Whether a payment is made depends on your insurance benefits, your coverage and benefit coordination.

Skilled Nursing Facility
An inpatient facility in which patients that do no need acute care are given nursing care or other therapy.

Specialist
A doctor who specializes in treating certain parts of the body or specific medical conditions. For example, a Cardiologist only treats patients with heart problems.

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

Summary of Accounts
A summary of services or charges mailed to the person who pays the bill.

Total Charges
The total price of your medical services.

UB-04
A form used by hospitals to file insurance claims for medical services. See CMS-1500.

Usual and Customary (U & C)
The costs for medical services that insurers believe are appropriate throughout a geographic area or community. Also referred to as Reasonable and Customary (R & C).