Billing Term Glossary
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 not to
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. The notice
is given to you so that 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
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, 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
Attending Physician – The doctor who orders your treatment and who is responsible for
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.
Beneficiary – A person covered by health insurance.
Beneficiary Eligibility Verification – A way providers retrieve information about whether you have insurance
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 Medicaid (CMS) – The federal agency that runs the Medicare program. In addition,
CMS works with the states to run the Medicaid programs
Certification Number - A number stating that your treatment has been approved by your insurance
plan. Also called an Authorization Number, Prior Authorization Number
or Treatment Authorization Number.
Champus – Insurance linked to military service, also known as TriCare.
Charity Care – Free or reduced rates for care provided to patients with financial
Claim – Your medical bill that is sent to an insurance company for payment.
Claim Form – A form provided by your insurance company that needs to be complete
before your bill can be paid.
Claim Number – A number assigned by your insurance company to an individual claim.
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.
Co-Insurance – The cost sharing part of your bill that you have to pay, such
as 10%. Your insurance company defines this amount. Your insurance company
indicates the amount you are responsible for in your insurance booklet.
Co-Insurance 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 the 90 th day you enter into your “Lifetime
Consent – 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 (Co-pay) – A type of cost sharing whereby the insured person pays a specified
flat dollar amount per service or visit, with the insurer paying the remainder
amount. For example, $10 per doctor visit, $25 per inpatient hospital day.
Covered Benefit – A health service or item that is included in your health plan
and is paid for either partially or fully.
Covered Days – The days that your insurance company pays for in full or in part.
CPT Codes – A coding system used to describe what treatments or services your
doctor gave to you.
Date of Bill – Bill preparation date. It is not the same date as the date of service.
Date of Service (DOS) – Treatment date.
Deductible – The amount you must pay for medical services before your insurance
company starts to pay.
Diagnosis Code – 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.
Discharge Hour – Hospital discharge hour.
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 Insurance - The amount owed by your insurance company.
Due from Patient – 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.
Eligible Payment Amount – The medical services paid for by an insurance company.
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.
Estimated Insurance – An estimate of payments from your insurance company.
Enrollee – A person who is covered by health insurance.
Estimated Amount Due – The amount the provider estimates you or your insurance company owes.
Explanation of Benefits (EOB/EOMB) – 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.
Federal Tax ID Number – A number assigned by the federal government to doctors and hospitals
for tax purposes.
Financial Responsibility – The amount of your bill you have to pay.
Fiscal Intermediary (FI) – A company hired by Medicare to pay Medicare claims.
Guarantor – The person responsible to pay the bill. The guarantor is always
the patient unless the patient is a child (< 18 years of age), a ward
of the court or a full-time student.
HCPC Codes – A coding system used to describe what treatment or services your
doctor or provider gave to you.
Healthcare 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 healthcare
advance directive may include a Living Will and a Durable Power of Attorney
for healthcare decisions.
Healthcare Provider – The party that provides medical services, such as hospitals, doctors
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 healthcare
for terminally ill patients.
Hospital Charge – The amount of money the hospital charges for a particular medical
service or supply.
Hospital Inpatient Prospective Payment System (PPS) – A federal system that pays a fixed fee for inpatient care.
Incremental Nursing Charge – The charges for nursing services added to basic room and board charges.
Inpatient (IP) – A patient who stays overnight in the hospital.
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
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
Internal Control Number (ICN) – A number assigned to your bill by your insurance company or their agent.
International Classification of Diseases, 9 th Edition (ICD-9-CM) – ICD-9-CM is the official system of assigning codes to diagnoses
and procedures associated with hospital utilization in the United States.
Liability –The person or persons liable or under obligation for the bill.
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.
Mailer/Summary of Account – A summary of services or charges mailed to the person who pays
Managed Care – An insurance plan that requires patients only see providers (doctors
and hospitals) that have a contract with the managed care company, except
in the case of medical emergencies or urgent care, if you are out of the
plans 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
Medicare + Choice – A Medicare HMO insurance plan that pays for preventive and other
types of healthcare provided by designated doctors and hospitals.
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 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 – Assists with paying for doctor services, outpatient care and other
medical services not paid for by Medicare part A.
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 Medicare Benefits. (EOMB).
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 healthcare
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 healthcare 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 healthcare 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.
Outpatient (OP) – A service you receive in one day at a hospital or clinic without
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.
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 that agrees to accept your insurance payment
for covered services as payment in full, minus your deductibles, co-pays
and co-insurance amounts.
Patient Amount Due – The amount your provider charges you for services received.
Pay This Amount – The amount you owe towards your medical bill.
Per Diem – The amount charged or paid by the day.
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. The staff includes personnel from patient accounts, medical
records, reception, lab and x-ray technicians, human resources and accounting.
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 Network (PCN) – A group of doctors serving as primary care doctors.
Primary Care Physician (PCP) – A doctor whose practice is devoted to internal medicine, family
and general practice or pediatrics. Some insurance companies consider
Obstetrician 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
Prior Authorization Number - A number stating that your treatment has been approved by your insurance
plan. It is also referred to as an Authorization Number, Certification
Number or Treatment Authorization Number.
Private Room – A more expensive hospital room compared to those available to
other patients. You may have to pay extra for this type of room, if it
is not a medical necessity.
Procedure code (CPT Code) – A code given to medical and surgical procedures and treatments.
Prospective Payment system (PPS) – A Medicare system that pays hospitals a set amount for covered
diagnostic or treatment services.
Provider Contract Discount – A part of your bill that your provider must write-off because of
billing agreements with your insurance company.
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.
Referral – Approval needed for care beyond that provided by your primary
care doctor or hospital. For example, managed care plans (HMO’s)
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.
Remittance Advice – The explanation the hospital receives, usually with payment, from
your insurance company after your medical services have been 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.
Same-Day Surgery – A surgery performed as an outpatient service.
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.
Service Area – A geographic area where insurance plans enroll members. In an HMO,
it is also the area served by your doctor network and hospitals.
Service Begin Date – The date your medical services or treatments began.
Service End Date – The date your medical services or treatments ended.
Skilled Nursing Facility – An inpatient facility in which patients that do no need acute
care are given nursing care or other therapy.
Source of Admission – The source of your admission whether it is a referral, transfer
or through the emergency room.
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.
Statement Covers Period – The dates your service or treatment begin and end.
Submitter ID – The identification number (ID) singles out doctors and hospitals
that bill by computer. Providers get an ID from each insurance company
to whom they send claims using the computer.
Supplemental Insurance Company – An additional insurance policy that handles claims for deductible
and co-insurance reimbursement.
Treatment Authorization Number - A number stating that your treatment has been approved by your insurance
plan. It is also referred to as an Authorization Number, Certification
Number or Prior Authorization Number.
Total Charges – The total cost of your medical services.
Type of Admission – The reason for your admission, such as emergency, urgent or elective, etc.
UB-04 - A form used by hospitals to file insurance claims for medical services.
Units of Service – Measures of medical services a patient received, such as the number
of hospital days, pints of blood, treatments or laboratory tests.
Usual and Customary (U & C) – The costs for medical services that insurers believe are appropriate
throughout a geographic area or community.