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Glossary of Billing Terms

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A

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Account Number - Number you’re given by your doctor or hospital for a medical visit.

Actual Charge - The amount of money a doctor or supplier charges for a certain medical service or supply. This amount is often more than the amount an insurance plan approves. *

Adjustment - The portion of your bill that your doctor or hospital has agreed not to charge you.

Admission Date (Admit Date) - Date you were admitted for treatment.

Admission Hour - Hour when you were admitted for inpatient or outpatient care.

Admitting Diagnosis - Words that your doctor uses to describe your condition

Advance Beneficiary Notice (ABN)
- A notice the hospital or doctor gives you before you’re treated, telling you that Medicare will not pay for some treatment or services. The notice is given to you so that you may decide whether to have the treatment and how to pay for it.

Advance Directive (Healthcare)
- Written ahead of time, a health care advance directive is a written document that says 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.*

All-inclusive Rate - Payment covering all services during your hospital stay.

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

Ambulatory Care - All types of health services that do not require an overnight hospital stay.*

Ambulatory Surgery
- Outpatient surgery or surgery that does not require an overnight hospital stay.

Amount Charged - how much your doctor or hospital bills you.

Amount Paid -The dollar amount that you paid for your doctor or hospital visit.

Amount Not Covered - What your insurance company does not pay. It includes deductibles, co-insurances, and charges for non-covered services.

Amount Payable by Plan - How much your insurer pays for your treatment, minus any deductibles, coinsurance, or charges for non-covered services.

Ancillary Service - Services you need beyond room and board charges, such as laboratory tests, therapy, surgery and the like.

Anesthesia - Drugs given to you during surgery to eliminate or reduce surgical procedure pain.

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 not pay for your care.

Applied to Deductible - Portion of your bill, as defined by your insurance company, that you owe your doctor or hospital.

Assignment - An agreement you sign that allows your insurance to pay the doctor or hospital directly.

Assignment of Benefits
- When insurance payments are sent directly to your doctor or hospital.

Attending Physician Name - The doctor who certifies that you need treatment and 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 or Prior-Authorization Number.

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Balance Bill - How much doctors and hospitals charge you after your health plan, insurance company, or Medicare have paid its approved amount.

Beneficiary - Person covered by health insurance.

Beneficiary Eligibility Verification
- A way for doctors and hospitals to get information about whether you have insurance coverage.

Beneficiary Liability
- A statement that you are responsible for some treatments or charges.

Benefit - The amount your insurance company pays for medical services.

Bill/Invoice/Statement - Printed summary of your medical bill.

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C



Cardiology Charges - Charges for heart procedures. Examples are heart catheterization and stress testing.

Case Management - A way to help you get the care you need, especially when you need pre-authorized care from several services. Usually a nurse helps arrange for your care.

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 program. CMS works to make sure that the beneficiaries in these programs are able to get high quality health care.*

CHAMPUS - Insurance linked to military service, also know as TriCare.

Charity Care - Free or reduced-fee care for patients who have financial hardship.

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

Claim Number - A number given to a medical service.

Clean Claim - A claim that does not have to be investigated by insurance companies before they process it.

Clinic - An area in a hospital or separate building that treats regularly scheduled or walk-in patients for non-emergency care.

COBRA Insurance
- Health insurance that you can buy when you lose your job. It is generally more expensive than insurance provided through your job but less expensive than insurance purchased on your own when you are unemployed.

Coding of Claims - Translating diagnoses and procedures in your medical record into numbers
that computers can understand.

Coinsurance - The cost sharing part of your bill that you have to pay.

Coinsurance Days (Medicare) - Hospital Inpatient Medicare coverage from day 61 to day 90 of continuous hospitalization. You are responsible for paying for part of those days. After the 90th day, you enter your "Lifetime Reserve Days."

Collection Agency - A business that collects money for unpaid bills.

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

Contractual Adjustment - A part of your bill that your doctor or hospital must write off (not charge you) because of billing agreements with your insurance company.

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

Co-pay - Agreed amount of the charges for medical services that patients or guarantors must pay.

Coronary Care - Routine charges for care you receive in a heart center because you need more care than you can get in a regular medical unit.

Covered Benefit
- A health service or item that is included in your health plan, and that is paid for either partially or fully.*

Covered Days - Days that your insurance company pays for in full or in part.

CPT Codes - A coding system used to describe what treatment or services were given to you by your doctor.

CT Scan - A type of X-ray of the head or body; usually done in a hospital’s x-ray department.

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D



Date of Bill - The date the bill for your services is prepared. It is not the same as the date of service.

Date of Service (DOS) - The date(s) when you were treated.

Days - The total number of days that you are being charged for the hospital’s services.

Deductible - How much cost sharing that you must pay for medical services often before your insurance company starts to pay.

Description of Services
- Tells what your doctor or hospital did for you.

Diagnosis Code - A code used for billing that describes your illness.

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

Discharge Hour - Hour when you were discharged.

Discount - Dollar amount taken off your bill, usually because of a contract with your hospital or doctor and your insurance company.

Drugs/Self Administered - Drugs that do not require doctors or nurses to help you when you take them. You may be charged for these. You will need to check with your doctor or hospital regarding their policy on this.

Due from Insurance - How much money is due from your insurance company.

Due from Patient - How much you owe your doctor or hospital.

Durable Medical Equipment (DME) - Medical equipment that can be used many times, or special equipment ordered by your doctor, usually for use at home.

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E



EEG - Equipment or medical procedure that measures electricity in the brain.

EKG/ECG - Equipment or medical procedure that measures how your heart works, and your doctor’s reading of the results.

Eligible Payment Amount - Those medical services that an insurance company pays for.

Emergency Care
- Care given for a medical emergency when you believe that your health is in serious danger when every second counts.*

Emergency Room - A special part of a hospital that treats patients with emergency or urgent medical problems.

Estimated Insurance
- Estimated cost paid by your insurance company.

Enrollee - A person who is covered by health insurance.

Estimated Amount Due - How much the doctor or hospital estimates you or your insurance company owes.

Explanation of Benefits (EOB/EOMB)
- The notice you receive from your insurance company after getting medical services from a doctor or hospital. It tells you what was billed, the payment amount approved by your insurance, the amount paid, and what you have to pay.

External Cause of Injury Code
- A code describing a place or item that may have caused injuries, poisoning, or health problems.

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 NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is taken from the Medicare Glossary, http://www.medicare.gov, February 2003