Key Billing Terms
Adjustment: A portion of your bill that your healthcare provider has agreed to write off.
Co-insurance: A method of cost-sharing between you and your insurance provider. You pay a percentage of costs as part of your contract with your insurance provider. You pay this amount even if your deductible has been met. For example, you may pay 20% of the costs of your services even after you have met your deductible.
Co-payment: The fixed dollar amount that you must pay out-of-pocket prior to or at the time of service. This amount is pre-determined and varies by insurance provider. It is based on your plan type and the type of service being provided. We are contractually obligated to collect co-payments from patients when a co-payment applies to the services being provided.
CPT code: Current Procedural Terminology code. A 5-digit standard for how medical professsionals document and report medical services and procedures. Insurance companies use CPT codes to help determine reimbursement amounts for practitioners. Using CPT codes enables healthcare providers and insurance companies to communicate and track billing more efficiently.
Deductible: The specified amount the patient must pay for healthcare expenses before insurance covers the remaining costs. It is your part of the contract with your insurance provider.
Guarantor: The individual responsible for paying the bill. Guarantors are usually the patient except in cases where the patient is incapacitated or an unemancipated minor in which case the the guarantor is the patient's parent or legal guardian. May also be referred to as the responsible party.
Health plan: refers to the type of insurance you have. You may be a part of a group health plan provided through your employer, or you may have purchased and individual plan on the Health Insurance Exchange. You could also be covered under workers' compensation for a work-related injury or have coverage through a government health plan such as Medicare or Medicaid.
HIPAA: Health Insurance Portability and Accountability Act. HIPAA sets standards for protecting the confidentiality of your health information.
HMO: Health maintenance organization. HMO health insurance plans require that enrolled patients received all healthcare from a specific group of providers, barring some emergency care. If you go outside of the HMO's network for non-emergency care, coverage disappears.
ICD-10-MC: International Classification of Diseases, 10th Revision, Clinical Modification is the tenth revision of the ICD coding system. ICD codes classify diagnoses and health issues of patients four to seven digit alphanumeric codes, which denote signs, symptoms, diseases, conditions, and injuries. Both CPT and ICD-10-CM codes must be provided to insurance companies for the provider to be reimbursed appropriately.
In network: The hospitals, doctors or other health care providers who have a contract with your insurance provider. The plan you have covers the costs of these health care providers. You may still have to pay a co-payment.
Insurance provider: A company you pay to help you cover your health care costs. This company has different plans and policies for its members. It makes payments to hospitals and health care providers on your behalf.
Managed care: A type of insurance plan that requires that requires patients to see only providers that have a contract with the managed care company, barring exceptions such as emergency or urgent care when the patient is outside of the plan's service area.
Medicaid: Jointly funded by federal and state governments, Medicaid provides free or low-cost health coverage to low-income individuals, families and children, pregnant women, the elderly, and people with disabilities.
Medicare: A federal health insurance program for those ages 65 and over, certain younger people with disabilities, and qualifying individuals with end-stage renal disease (permanent kidney failure requiring dialysis or a transplant). Find complete information at https://www.medicare.gov/
Out of network: Hospitals, physicians or other health care providers who do not have a contract with your insurance provider. Your insurance will not cover the costs, so you will be responsible for paying for the services provided to you.
Out-of-pocket costs: Health care costs, such as deductibles, co-payments and co-insurance, that are not covered by insurance. Out-of-pock costs do not include premium costs.
Out-of-pocket maximum: A yearly cap on the amount of money you are required to pay out-of-pocket for healthcare costs, but not including the premium cost. Some insurance companies do not include certain costs in this limit; examples might incude fertility treatments or prescription drugs.
Payer: Another name for an insurance company
Pre-admission approval or certification (pre-authorization): An agreement made by your insurance company and you or your healthcare provider stating that the insurance company will pay their portion of your medical costs. Providers ask your insurance company for pre-admission approval before providing medical services.
PPO: Preferred Provider Organization. A healthcare organization that covers a larger amount of a patient's healthcare costs if they use the services of a provider on their preferred provider list. Unlike HMOs, PPOs do not restrict patients to only the providers within their network in order for costs to be covered.
Premium: The amount you pay, often monthly, for health insurance. The cost of the premium may be shared between employers and government purchasers and patients.
Provider: A hospital or physician who provides medical care.
Waiting period: The amount of time members must wait after enrolling in an insurance plan before they become eligible to receive certain benefits.