Billing Terms
Ambulatory Surgical Center / A medical facility designed and equipped to handle surgery, pain management, and certain diagnostic procedures that do not require overnight hospitalization. Most patients who are in relatively good health may receive treatment at ambulatory surgery centers.Appeal / The formal process to have the insurance company reconsider a claim
Auto insurance / Insurance billed due to an auto accident
Bad Debt / A person or persons whose account has been sent to an external collection agency for further action
Balance statement / A statement that shows a balance on an account which has not been paid
Benefit coverage / Services provided to plan members as described by insurance policy
Claim / A demand for payment in accordance with an insurance policy
Co-insurance / The percentage of treatment cost for which the consumer is responsible on an insurance claim
Co-pay/Co-payment / The fixed dollar amount the consumer must pay for each surgery
Deductible / The annual amount the consumer must pay for medical services (excluding premiums) before the insurance plan begins covering costs
Exclusions / Medical services not covered by an insurance policy
Fee for service / A plan in which the insurance company and consumer share the cost of treatment according to a fixed ratio. (For example, the company might pay 80 percent, while the consumer pays 20 percent in co-insurance)
HDHP/High-deductible health plan / A plan that offers lower monthly premiums but much higher deductibles (often more than $2,000 for individuals and $5,000 for families) than typical managed-care plans
HMO/Health Maintenance Organization / A health maintenance organization, or HMO, offers insurance plans in which the consumer pays a modest co-payment, but coverage is restricted to participating facilities. Specialist care can require a referral from a primary care provider
HSA/Health Savings Account / Atax-free, portable savings account that is used to pay medical expenses. Unused funds can be carried over from year to year. Requires enrollment in a high-deductible health plan (HDHP).
In-network / A term that refers to the fact that a doctor or hospital is part of the group (network) whose services are covered by an insurance plan at the maximum rate
Insurance company / A financial institution that sells insurance
Insured / A person or persons; who is a policyholder of an insurance policy. Also known as the subscriber, policyholder, cardholder, beneficiary or consumer
Medicaid / A federal and state-funded program that pays for medical care for those who cannot afford it
Medicare / A federal program that helps pay for medical care for people age 65 and older, or who have certain disabilities. Those enrolled are responsible for premiums, deductibles and co-payments
Out-of-network / A term that refers to the fact that a doctor or hospital is not part of the group (network) whose services are covered by an insurance plan at the maximum rate
Outpatient / A patient who is admitted to a hospital or clinic for treatment that does not require an overnight stay.
Out of Pocket Expenses / A term that refers to the amount of money that the insured pays not including the premuims, these can include deductibles, co-payments and co-insurance. Once met, the insurance provider will cover medical claims 100%
PCP/Primary Care Physician / A doctor chosen by a patient in a managed-care plan to provide routine care, as well as referrals to medical specialists
POS/Point-of-service plan / An option, also called a point-of-service plan, offered with certain health maintenance organizations (HMOs) allowing for some coverage for out-of-network treatment. Consumer often can visit specialists without a referral from a primary-care physician
PPO/Preferred Provider Organization / An insurance plan in which the consumer pays a co-payment for visits to in-network doctors. PPOs partially cover treatment by out-of-network doctors
Personal injury / When a person has suffered some form of injury, either physical or psychological, as the result of an accident
Plan / A program or policy stipulating a service or benefit
Policy / A written contract or certificate of insurance
Pre-authorization / An insurance plan requirement that you or your primary doctor need to notify the insurance in advance of certain medical procedures or inpatient stays
Pre-existing condition / A medical condition not covered by an insurer because the consumer is believed to have had the condition prior to obtaining the policy
Premium / A fee paid by the consumer for participation in a health plan
Prescription / A written order, especially by a physician, for the preparation and administration of a medicine or other treatment.
Referral / The recommendation of a medical professional
Secondary claim / A request for payment after a primary insurance has processed a claim
Self-Pay / Uninsured patient who has no third party insurance coverage
Stop-loss / The point at which a consumer has fully paid the deductible and reached the maximum amount of co-payment required by an insurance policy. Insurance covers 100 percent of additional costs for the remainder of the year
Worker's compensation / Payments required by law to be made to an employee who is injured or disabled in connection with work