Chaitanya MB <mbc.chaitu@gmail.

com>

Healthcare Terminologies
Chaitanya MB <[email protected]> Sun, 5 Apr 2020 at 9:13 PM
To: <[email protected]>, <[email protected]>

Health Care.. Terminologies

ACA - Affordable Care Act. Also referred

to as "ObamaCare". A Federal law
enacted in 2010 intended to increase
healthcare coverage and make it more
affordable. It also expands Medicaid
eligibility and guarantees coverage
without regard to pre-existing medical
conditions.

Accept Assignment - When a

healthcare provider accepts as full
payment the amount paid on a claim by
the insurance company. This excludes
patient responsible amounts such as
coinsurance or copay.

Adjusted Claim - When a claim is

corrected which results in a credit or
payment to the provider

Allowed Amount - The reimbursement

amount an insurance company will pay
for a healthcare procedure. This amount
varies depending on the patients
insurance plan. For 80/20 insurance, the
provider accepts 80% of
the allowed amount and the patient
pays the remaining 20%.

AMA - American Medical Association.

The AMA is the largest association of
doctors in the United States. They
publish the Journal of American Medical
Association which is one of the most
widely circulated medical journals in the
world.

Aging - One of the medical billing terms

referring to the unpaid insurance claims
or patient balances that are due past 30
days. Most medical billing software's
have the ability to generate a separate
report for insurance aging and patient
aging. These reports typically list
balances by 30, 60, 90, and 120 day
increments.

Ancillary Services - These are typically

services a patient requires in a hospital
setting that are in addition to room and
board accommodations - such as
surgery, lab tests, counseling, therapy,
etc.

Appeal - When an insurance plan does

not pay for treatment, an appeal (either
by the provider or patient) is the process
of objecting this decision. The insurer
may require documentation when
processing an appeal and typically has a
formal policy or process established for
submitting an appeal. Many times the
process and associated forms can be
found on the insurance providers web
site.

Applied to Deductible (ATD) - You

typically see these medical billing terms
on the patient statement. This is the
amount of the charges, determined by
the patients insurance plan, the patient
owes the provider. Many plans have a
maximum annual deductible that once
met is then covered by the insurance
provider.

Assignment of Benefits (AOB) -

Insurance payments that are paid
directly to the doctor or hospital for a
patients treatment. This is designated in
Box 27 of the CMS-1500 claim form.

ASP - Application Service Provider. This

is a computer based services over a
network for a particular application.
Sometimes referred to as SaaS
(Software as a Service). There
application service providers that offer
Medical Billing. The appeal of an ASP is it
frees a business of the the need to
purchase, maintain, and backup software
and servers.

Authorization - When a patient

requires permission (or authorization)
from the insurance company before
receiving certain treatments or services.

Beneficiary - Person or persons covered

by the health insurance plan and eligible
to receive benefits.

Blue Cross Blue Shield (BCBS) - An

organization of affiliated insurance
companies (approximately 450),
independent of the association (and each
other), that offer insurance plans within
local regions under one or both of the
association's brands (Blue Cross or Blue
Shield). Many local BCBS associations
are non-profit BCBS sometimes acts as
administrators of Medicare in many
states or regions.

Capitation - A fixed payment paid per

patient enrolled over a defined period of
time, paid to a health plan or provider.
This covers the costs associated with the
patients health care services. This
payment is not affected by the type or
number of services provided.

Carrier - Simply the insurance company

or "carrier" the patient has a contract
with to provide health insurance.

Category I Codes - Codes for medical

procedures or services identified by the 5
digit CPT Code.

Category II Codes - Optional

performance measurement tracking
codes which are numeric with a letter as
the last digit (example: 9763B).

Category III Codes - Temporary codes

assigned for collecting data which are
numeric followed by a letter in the last
digit (example: 5467U).

CHAMPUS - Civilian Health and Medical

Program of the Uniformed Services.
Recently renamed TRICARE. This is
federal health insurance for active duty
military, National Guard and Reserve,
retirees, their families, and survivors.

Charity Care - When medical care is

provided at no cost or at reduced cost to
a patient that cannot afford to pay.

Clean Claim - Medical billing term for a

complete submitted insurance claim that
has all the necessary correct information
without any omissions or mistakes that
allows it to be processed and paid
promptly.

Clearinghouse - This is a service that

transmits claims to insurance carriers.
Prior to submitting claims the
clearinghouse scrubs claims and checks
for errors. This minimizes the amount of
rejected claims as most errors can be
easily corrected. Clearinghouses
electronically transmit claim information
that is compliant with the strict HIPPA
standards (this is one of the medical
billing terms we see a lot more of lately).

CMS - Centers for Medicaid and Medicare

Services. Federal agency which
administers Medicare, Medicaid, HIPPA,
and other health programs. Formerly
known as the HCFA (Health Care
Financing Administration). You'll notice
that CMS it the source of a lot of medical
billing terms.

CMS 1500 - Medical claim form

established by CMS to submit paper
claims to Medicare and Medicaid. Most
commercial insurance carriers also
require paper claims be submitted on
CMS-1500's. The form is distinguished
by it's red ink.

Coding - Medical Billing Coding involves

taking the doctors notes from a patient
visit and translating them into the proper
diagnosis (ICD-9 or ICD-10 code) and
treatment medical billing codes such as
CPT codes. This is for the purpose of
reimbursing the provider and classifying
diseases and treatments.

COBRA Insurance - This is health

insurance coverage available to an
individual and their dependents after
becoming unemployed - either voluntary
or involuntary termination of
employment for reasons other than
gross misconduct. Because it does not
typically receive company matching, It's
typically more expensive than insurance
the cost when employed but does benefit
from the savings of being part of a group
plan. Employers must extend COBRA
coverage to employees dismissed for a.
COBRA stands for Consolidated Omnibus
Budget Reconciliation Act which was
passed by Congress in 1986.

COBRA coverage typically lasts up to 18

months after becoming unemployed and
under certain conditions extend up to 36
months.

Co-Insurance - Percentage or amount

defined in the insurance plan for which
the patient is responsible. Most plans
have a ratio of 90/10 or 80/20, 70/30,
etc. For example the insurance carrier
pays 80% and the patient pays 20%.

Collection Ratio - This is in reference to

the providers accounts receivable. It's
the ratio of the payments received to the
total amount of money owed on the
providers accounts.

Contractual Adjustment - The amount

of charges a provider or hospital agrees
to write off and not charge the patient
per the contract terms with the
insurance company.

Coordination of Benefits (COB) -

When a patient is covered by more than
one insurance plan. One insurance
carrier is designated as the primary
carrier and the other as secondary.

Co-Pay - Amount paid by patient at

each visit as defined by the insured plan.

CPT Code - Current Procedural

Terminology. This is a 5 digit code
assigned for reporting a procedure
performed by the physician. The CPT has
a corresponding ICD-9 diagnosis code.
Established by the American Medical
Association. This is one of the medical
billing terms we use a lot.

Credentialing - This is an application

process for a provider to participate with
an insurance carrier. Many carriers now
request credentialing through CAQH.
The CAQH credentialing process is a
universal system now accepted by
insurance company networks.

Credit Balance - The balance thats

shown in the "Balance" or "Amount Due"
column of your account statement with a
minus sign after the amount (for
example $50-). It may also be shown in
parenthesis; ($50). The provider may
owe the patient a refund.

Crossover claim - When claim

information is automatically sent from
Medicare the secondary insurance such
as Medicaid.

Date of Service (DOS) - Date that

health care services were provided.

Day Sheet - Summary of daily patient

treatments, charges, and payments
received.

Deductible - amount patient must pay

before insurance coverage begins. For
example, a patient could have a $1000
deductible per year before their health
insurance will begin paying. This could
take several doctor's visits or
prescriptions to reach the deductible.

Demographics - Physical characteristics

of a patient such as age, sex, address,
etc. necessary for filing a claim.

DME - Durable Medical Equipment -

Medical supplies such as wheelchairs,
oxygen, catheter, glucose monitors,
crutches, walkers, etc.

DOB - Abbreviation for Date of Birth

Downcoding - When the insurance

company reduces the code (and
corresponding amount) of a claim when
there is no documentation to support the
level of service submitted by the
provider. The insurers computer
processing system converts the code
submitted down to the closest code in
use which usually reduces the payment.

Duplicate Coverage Inquiry (DCI) -

Request by an insurance company or
group medical plan by another insurance
company or medical plan to determine if
other coverage exists.

Dx - Abbreviation for diagnosis code

(ICD-9 or ICD-10 code).

Electronic Claim - Claim information is

sent electronically from the billing
software to the clearinghouse or directly
to the insurance carrier. The claim file
must be in a standard electronic format
as defined by the receiver.

Electronic Funds Transfer (EFT) - An

electronic paperless means of
transferring money. This allows funds to
be transferred, credited, or debited to a
bank account and eliminates the need
for paper checks.

E/M - Medical billing terms for the

Evaluation and Management section of
the CPT codes. These are the CPT codes
99201 thru 99499 most used by
physicians to access (or evaluate) a
patients treatment needs.

EMR - Electronic Medical Records. Also

referred to as EHR (Electronic Health
Records). This is a medical record in
digital format of a patients hospital or
provider treatment. An EMR is the
patient's medical record managed at the
providers location. The EHR is a
comprehensive collection of the patients
medical records created and stored at
several locations.

Encryption - Conversion of data into a

form that cannot be easily seen by
someone who is not
authorized. Encrypted emails may be
used when sending patient info to
comply with HIPAA requirements for
protection of patient information.

Enrollee - Individual covered by health

insurance.
EOB - Explanation of Benefits. One of
the medical billing terms for the
statement that comes with the insurance
company payment to the provider
explaining payment details, covered
charges, write offs, and patient
responsibilities and deductibles.

ERA - Electronic Remittance Advice. This

is an electronic version of an insurance
EOB that provides details of insurance
claim payments. These are formatted in
according to the HIPAA X12N 835
standard.

ERISA - Employee Retirement Income

Security Act of 1974. This law
established the reporting, disclosure of
grievances, and appeals requirements
and financial standards for group life and
health. Self-insured plans are regulated
by this law.

Errors and Omissions Insurance -

Liability insurance for professionals to
cover mistakes which may cause
financial harm to another part.

Fair Debt Collection Practices Act

(FDCPA) - Federal law that regulates
creditor or collection agency practices
when trying to collect on past due
accounts.

Fee For Service - Insurance where the

provider is paid for each service or
procedure provided. Typically allows
patient to choose provider and hospital.
Some policies require the patient to pay
provider directly for services and submit
a claim to the carrier for reimbursement.
The trade-off for this flexibility is usually
higher deductibles and co-pays.

Fee Schedule - Cost associated with

each CPT treatment billing code for a
providers treatment or services.

Financial Responsibility - The portion

of the charges that are the responsibility
of the patient or insured.

Fiscal Intermediary (FI) - A Medicare

representative who processes Medicare
claims.

Formulary - A list of prescription drug

costs which an insurance company will
provide reimbursement for.

Fraud - When a provider receives

payment or a patient obtains services by
deliberate, dishonest, or misleading
means.

GPH - Group Health Plan. A means for

one or more employer who provide
health benefits or medical care for their
employees (or former employees).

Group Name - Name of the group or

insurance plan that insures the patient.

Group Number - Number assigned by

insurance company to identify the group
under which a patient is
insured.Guarantor - A responsible party
and/or insured party who is not a
patient.
HCFA - Health Care Financing
Administration. Now know as CMS (see
above in Medical Billing Terms).

HCPCS - Health Care Financing

Administration Common Procedure
Coding System. (pronounced "hick-
picks"). Three level system of codes. CPT
is Level I. A standardized medical coding
system used to describe specific items or
services provided when delivering health
services. May also be referred to as a
procedure code in the medical billing
glossary.

The three HCPCS levels are:

Level I - American Medical

Associations Current Procedural
Terminology (CPT) codes.
Level II - The alphanumeric codes
which include mostly non-physician
items or services such as medical
supplies, ambulatory services,
prosthesis, etc. These are items and
services not covered by CPT (Level
I) procedures.
Level III - Local codes used by state
Medicaid organizations, Medicare
contractors, and private insurers for
specific areas or programs.

Health Savings Account - Also called

Flexible Spending Account. A tax exempt
account provided by an employer from
which an employee can pay health care
related expenses. The current limit is
$2500 per year.

Healthcare Insurance - Insurance

coverage to cover the cost of medical
care necessary as a result of illness or
injury. May be an individual policy or
family policy which covers the
beneficiary's family members. May
include coverage for disability or
accidental death or dismemberment.

Medical Billing Glossary

Heathcare Provider - Typically a

physician, hospital, nursing facility, or
laboratory that provides medical care
services. Not to be confused with
insurance providers or the organization
that provides insurance coverage.

Health Care Reform Act - Health care

legislation championed by President
Obama in 2010 to provide improved
individual health care insurance or
national health care insurance for
Americans. Also referred to as the Health
Care Reform Bill or the Obama Health
Care Plan.

HIC - Health Insurance Claim. This is a

number assigned by the the Social
Security Administration to a person to
identify them as a Medicare beneficiary.
This unique number is used when
processing Medicare claims.

HIPAA - Health Insurance Portability

and Accountability Act. Several federal
regulations intended to improve the
efficiency and effectiveness of health
care and establish privacy and security
laws for medical records. HIPAA has
introduced a lot of new medical billing
terms into our vocabulary lately.

HMO - Health Maintenance Organization.

A type of health care plan that places
restrictions on treatments.

Hospice - Inpatient, outpatient, or

home healthcare for terminally ill
patients.

ICD-9 Code - Also know as ICD-9-CM.

International Classification of Diseases
classification system used to assign
codes to patient diagnosis. This is a 3 to
5 digit number.

ICD 10 Code - 10th revision of the

International Classification of Diseases.
Uses 3 to 7 digit. Includes additional
digits to allow more available codes. The
U.S. Department of Health and Human
Services has set an implementation
deadline of October, 2013 for ICD-10.

Incremental Nursing Charge -

Charges for hospital nursing services in
addition to basic room and board.

Indemnity - Also referred to as fee-for-

service. This is a type of commercial
insurance were the patient can use any
provider or hospital

In-Network (or Participating) - An

insurance plan in which a provider signs
a contract to participate in. The provider
agrees to accept a discounted rate for
procedures.

Inpatient - Hospital stay of more than

one day (24 hours).

IPA - Independent Practice Association.

An organization of physicians that are
contracted with a HMO plan.

Intensive Care - Hospital care unit

providing care for patients who need
more than the typical general medical or
surgical area of the hospital can provide.
May be extremely ill or seriously injured
and require closer observation and/or
frequent medical attention.

MAC - Medicare Administrative

Contractor.

Managed Care Plan - Insurance plan

requiring patient to see doctors and
hospitals that are contracted with the
managed care insurance company.
Medical emergencies or urgent care are
exceptions when out of the managed
care plan service area.

Maximum Out of Pocket - The

maximum amount the insured is
responsible for paying for eligible health
plan expenses. When this maximum limit
is reached, the insurance typically then
pays 100% of eligible expenses.

Meaningful Use - A provision of the

2009 HITECH act that provides stimulus
money to providers who implement
Electronic Health Records (EHR).
Providers who implement EHR must
show "Meaningful Use" and meet certain
requirements defined in the act. The
incentive is $63,750 over 6 years for
Medicaid and $44,000 over 5 years for
Medicare. Providers who do not
implement EHR by 2015 are penalized
1% of Medicare payments increasing to
3% over 3 years.

Medical Assistant - A health care

worker who performs administrative and
clinical duties in support of a licensed
health care provider such as a physician,
physicians assistant, nurse, nurse
practitioner, etc.

Medical Coder - Analyzes patient charts

and assigns the appropriate code. These
codes are derived from ICD-9 codes
(soon to be ICD-10) and corresponding
CPT treatment codes and any related
CPT modifiers.

Medical Billing Specialist - Processes

insurance claims for payment of services
performed by a physician or other health
care provider. Ensures patient medical
billing codes, diagnosis, and insurance
information are entered correctly and
submitted to insurance payer. Enters
insurance payment information and
processes patient statements and
payments. Performs tasks vital to the
financial operation of a practice.
Knowledgeable in medical billing
terminology.

Medical Necessity - Medical service or

procedure that is performed on for
treatment of an illness or injury that is
not considered investigational, cosmetic,
or experimental.

Medical Record Number - A unique

number assigned by the provider or
health care facility to identify the patient
medical record.

MSP - Medicare Secondary Payer.

Medical Savings Account - Tax

exempt account for paying medical
expenses administered by a third party
to reimburse a patient for eligible health
care expenses. Typically provided by
employer where the employee
contributes regularly to the account
before taxes and submits claims or
receipts for reimbursement. Sometimes
also referred to in medical billing
terminology as a Medical Spending
Account.

Medical Transcription - The conversion

of voice recorded or hand written
medical information dictated by health
care professionals (such as physicians)
into text format records. These records
can be either electronic or paper.

Medicare - Insurance provided by

federal government for people over 65 or
people under 65 with certain restrictions.
There are 2 parts:

Medicare Part A - Hospital

coverage
Medicare Part B - Physicians visits
and outpatient procedures
Medicare Part D - Medicare
insurance for prescription drug
costs for anyone enrolled in
Medicare Part A or B.

Medicare Coinsurance Days - Medical

billing terminology for inpatient hospital
coverage from day 61 to day 90 of a
continuous hospitalization. The patient is
responsible for paying for part of the
costs during those days. After the 90th
day, the patient enters "Lifetime Reserve
Days."

Medicare Donut Hole - The gap or

difference between the initial limits of
insurance and the catastrophic Medicare
Part D coverage limits for prescription
drugs.

Medicaid - Insurance coverage for low

income patients. Funded by Federal and
state government and administered by
states.

Medigap - Medicare
supplemental health insurance for
Medicare beneficiaries which may include
payment of Medicare deductibles, co-
insurance and balance bills, or other
services not covered by Medicare.

Modifier - Modifier to a CPT treatment

code that provide additional information
to insurance payers for procedures or
services that have been altered or
"modified" in some way. Modifiers are
important to explain additional
procedures and obtain reimbursement
for them.

N/C - Non-Covered Charge. A procedure

not covered by the patients health
insurance plan.

NEC - Not Elsewhere Classifiable.

Medical billing terminology used in ICD
when information needed to code the
term in a more specific category is not
available.

Network Provider - Health care

provider who is contracted with an
insurance provider to provide care at a
negotiated cost.

Nonparticipation - When a healthcare

provider chooses not to accept Medicare-
approved payment amounts as payment
in full.

NOS - Not Otherwise Specified. Used in

ICD for unspecified diagnosis.

NPI Number - National Provider

Identifier. A unique 10 digit identification
number required by HIPAA and assigned
through theNational Plan and Provider
Enumeration System (NPPES).

OIG - Office of Inspector General - Part

of department of Health and Human
Services. Establish compliance
requirements to combat healthcare fraud
and abuse. Has guidelines for billing
services and individual and small group
physician practices.

Out-of Network (or Non-

Participating) - A provider that does
not have a contract with the insurance
carrier. Patients usually responsible for a
greater portion of the charges or may
have to pay all the charges for using an
out-of network provider.
Out-Of-Pocket Maximum - The
maximum amount the patient has to pay
under their insurance policy. Anything
above this limit is the insurers obligation.
These Out-of-pocket maximums can
apply to all coverage or to a specific
benefit category such as prescriptions.

Outpatient - Typically treatment in a

physicians office, clinic, or day surgery
facility lasting less than one day.

Palmetto GBA - An administrator of

Medicare health insurance for the
Centers for Medicare & Medicaid Services
(CMS) in the US and its territories. A
wholly owned subsidiary of BlueCross
BlueShield of South Carolina based in
Columbia, South Carolina.

Patient Responsibility - The amount a

patient is responsible for paying that is
not covered by the insurance plan.

PCP - Primary Care Physician - Usually

the physician who provides initial care
and coordinates additional care if
necessary.

POS - Point-of-Service plan. Medical

billing terminology for a flexible type of
HMO (Health Maintenance Organization)
plan where patients have the freedom to
use (or self-refer to) non-HMO network
providers. When a non-HMO specialist is
seen without referral from the Primary
Care Physician (self-referral), they have
to pay a higher deductible and a
percentage of the coinsurance.

POS (Used on Claims) - Place of

Service. Medical billing terminology used
on medical insurance claims - such as
the CMS 1500 block 24B. A two digit
code which defines where the procedure
was performed. For example 11 is for
the doctors office, 12 is for home, 21 is
for inpatient hospital, etc.

PPO - Preferred Provider Organization.

Commercial insurance plan where the
patient can use any doctor or hospital
within the network. Similar to an HMO.

Practice Management Software -

software used for the daily operations of
a providers office. Typically used for
appointment scheduling and billing.

Preauthorization - Requirement of
insurance plan for primary care doctor to
notify the patient insurance carrier of
certain medical procedures (such as
outpatient surgery) for those procedures
to be considered a covered expense.

Pre-Certification - Sometimes required

by the patients insurance company to
determine medical necessity for the
services proposed or rendered. This
doesn't guarantee the benefits will be
paid.

Predetermination - Maximum payment

insurance will pay towards surgery,
consultation, or other medical care -
determined before treatment.

Pre-existing Condition (PEC) - A

medical condition that has been
diagnosed or treated within a certain
specified period of time just before the
patients effective date of coverage. A
Pre-existing condition may not be
covered for a determined amount of time
as defined in the insurance terms of
coverage (typically 6 to 12 months).

Pre-existing Condition Exclusion -

When insurance coverage is denied for
the insured when a pre-existing medical
condition existed when the health plan
coverage became effective.
Premium - The amount the insured or
their employer pays (usually monthly) to
the health insurance company for
coverage.

Privacy Rule - The HIPAA privacy

standard establishes requirements for
disclosing what the HIPAA privacy law
calls Protected Health Information (PHI).
PHI is any information on a patient about
the status of their health, treatment, or
payments.

Protected Health Information

(PHI) - An individuals identifying
information such as name, address, birth
date, Social Security Number, telephone
numbers, insurance ID numbers, or
information pertaining to healthcare
diagnosis or treatment.

Provider - Physician or medical care

facility (hospital) who provides health
care services.

PTAN - Provider Transaction Access

Number. Also known as the legacy
Medicare number.

Referral - When one provider (usually a

family doctor) refers a patient to another
provider (typically a specialist).

Remittance Advice (R/A) - A

document supplied by the insurance
payer with information on claims
submitted for payment. Contains
explanations for rejected or denied
claims. Also referred to as an EOB
(Explanation of Benefits).

Responsible Party - The person

responsible for paying a patients medical
bill. Also referred to as the guarantor.

Revenue Code - Medical billing

terminology for a 3-digit number used on
hospital bills to tell the insurer where the
patient was when they received
treatment, or what type of item a patient
received.

RVU - Relative Value Amount. This is the

average amount Medicare will pay a
provider or hospital for a procedure
(CPT-4). This amount varies depending
on geographic location.

Scrubbing - Process of checking an

insurance claim for errors in the health
insurance claim software prior to
submitting to the payer.

Self-Referral - When a patient sees a

specialist without a primary physician
referral.

Self Pay - Payment made at the time of

service by the patient.

Secondary Insurance Claim - claim

for insurance coverage paid after the
primary insurance makes payment.
Secondary insurance is typically used to
cover gaps in insurance coverage.

Secondary Procedure - When a second

CPT procedure is performed during the
same physician visit as the primary
procedure.

Security Standard - Provides guidance

for developing and implementing policies
and procedures to guard and mitigate
compromises to security. The HIPAA
security standard is kind of a sub-set or
compliment to the HIPAA privacy
standard. Where the HIPAA policy
privacy requirements apply to all patient
Protected Health Information (PHI),
HIPAA policy security laws apply more
specifically to electronic PHI.

Skilled Nursing Facility - A nursing

home or facility for convalescence.
Provides a high level of specialized care
for long-term or acutely ill patients. A
Skilled Nursing Facility is an alternative
to an extended hospital stay or home
nursing care.

SOF - Signature on File.

Software As A Service (SAAS) - One

of the medical billing terms for a
software application that is hosted on a
server and accessible over the Internet.
SAAS relieves the user of software
maintenance and support and the need
to install and run an application on an
individual local PC or server. Many
medical billing applications are available
as SAAS.

Specialist - Pphysician who specializes

in a specific area of medicine, such as
urology, cardiology, orthopedics,
oncology, etc. Some heathcare plans
require beneficiaries to obtain a referral
from their primary care doctor before
making an appointment to see a
Specialist.
Subscriber - Medical billing term to
describe the employee for group policies.
For individual policies the subscriber
describes the policyholder.

Superbill - One of the medical billing

terms for the form the provider uses to
document the treatment and diagnosis
for a patient visit. Typically includes
several commonly used ICD-9 diagnosis
and CPT procedural codes. One of the
most frequently used medical billing
terms.

Supplemental Insurance - Additional

insurance policy that covers claims fro
deductibles and coinsurance. Frequently
used to cover these expenses not
covered by Medicare.

TAR - Treatment Authorization Request.

An authorization number given by
insurance companies prior to treatment
in order to receive payment for services
rendered.

Taxonomy Code - Specialty standard

codes used to indicate a providers
specialty sometimes required to process
a claim.

Term Date - Date the insurance

contract expired or the date a subscriber
or dependent ceases to be eligible.

Tertiary Insurance Claim - Claim for

insurance coverage paid in addition to
primary and secondary insurance.
Tertiary insurance covers gaps in
coverage the primary and secondary
insurance may not cover.

Third Party Administrator (TPA) - An

independent corporate entity or person
(third party) who administers group
benefits, claims and administration for a
self-insured company or group.

TIN - Tax Identification Number. Also

known as Employer Identification
Number (EIN).
TOP - Triple Option Plan. An insurance
plan which offers the enrolled a choice of
a more traditional plan, an HMO, or a
PPO. This is also commonly referred to
as a cafeteria plan.

TOS - Type of Service. Description of the

category of service performed.

TRICARE - This is federal health

insurance for active duty military,
National Guard and Reserve, retirees,
their families, and survivors. Formerly
know as CHAMPUS.

UB04 - Claim form for hospitals, clinics,

or any provider billing for facility fees
similar to CMS 1500. Replaces the UB92
form.

Glossary of Billing Terms

Unbundling - Submitting several CPT

treatment codes when only one code is
necessary.

Untimely Submission - Medical claim

submitted after the time frame allowed
by the insurance payer. Claims
submitted after this date are denied.

Upcoding - An illegal practice of

assigning an ICD-9 diagnosis code that
does not agree with the patient records
for the purpose of increasing the
reimbursement from the insurance
payor.

UPIN - Unique Physician Identification

Number. 6 digit physician identification
number created by CMS. Discontinued in
2007 and replaced by NPI number.
Usual Customary &
Reasonable(UCR) - The allowable
coverage limits (fee schedule)
determined by the patients insurance
company to limit the maximum amount
they will pay for a given service or item
as defined in the contract with the
patient.

Utilization Limit - The limits that

Medicare sets on how many times
certain services can be provided within a
year. The patients claim can be denied if
the services exceed this limit.

Utilization Review (UR) - Review or

audit conducted to reduce unnecessary
inpatient or outpatient medical services
or procedures.

V-Codes - ICD-9-CM coding

classification to identify health care for
reasons other than injury or illness.

Workers Comp - Insurance claim that

results from a work related injury or
illness.

Write-off - Typically reference to the

difference between what the physician
charges and what the insurance plan
contractually allows and the patient is
not responsible for. May also be referred
to as "not covered" in some glossary of
billing terms.