Glossary of Billing & Insurance Terms

The following is a list of frequently used billing and insurance terms that can help you understand the meaning of some terminology used in medical bills and by your insurance carrier.

Please do not hesitate to contact one of our patient account technicians if confused about any part of your medical bill. Patient account technicians are available to assist you Monday through Friday, 8am - 4:30pm at (757)668-8931 and 5pm - 9pm at (757)668-7682.

A - E

admission - the admittance of a patient to a licensed hospital for a period of not less than 24 hours.

appeal - any written communication from a member which clearly expresses that he or she wants to present his or her case for review.

authorized service - covered benefit that has been approved by your managed care plan or by your primary care physician (PCP).

benefits package or benefit schedule summary - description of covered health care services that your managed care plan will provide for you and your family.

capitation - reimbursement based on a per-patient fee in exchange for services provided by a physician.

copayment - the portion of a health insurance claim that a member must pay.

dependent - a managed care plan enrollee who is a member of your immediate family.

deductible - the health care expenses that must be paid by you before insurance coverage applies.

EPSDT - Early and Periodic Screening, Diagnosis and Treatment program; a well-child program required for children and teenagers under the age of twenty-one years.

eligible member - a person covered by an insurance plan.

emergency - the sudden and unexpected medical condition that would lead to one or more of the following: (1) result in serious impairment (risk) to the individuals bodily functions or organs, (2) pose a serious threat to life or limb or harm to others, or (3) in the case of a pregnant woman, cause serious jeopardy to the health of the mother or unborn child.

F - N

fee-for-service - reimbursement based on the cost of services provided.

health services - health care services and supplies covered by the member’s benefit plan.

health maintenance organization (HMO) - an insurance plan that consists of a network of primary care doctors/PCP’s, specialists, hospitals and health education services available to its members. Typically members are not covered to obtain care from providers who do not have a contract with the HMO.

hospital - a facility that provides medical inpatient and outpatient health care services.

managed care - a variety of health care financing and delivery systems that are designed to limit costs and the quality of health care services.

medically necessary or medically needed - services that you must have for the treatment of an illness or injury as determined by you doctor/PCP.

member - an individual who is properly covered under a benefit contract.

member expense - any amounts that are the member’s responsibility to pay the hospital or the physician in accordance with the member’s benefit contract, including copayments, coinsurance and deductibles.

network - group of physicians who agree to provide care to members and to abide by the rules of the insurance plan.

non-participating provider - a health care professional or facility that does not have a written participating agreement with an insurance plan.

O - Z

participating provider - a health care professional or facility that has a written participation agreement with an insurance plan.

point-of-service (POS) plan- a form of HMO that provides some coverage for services provided by physicians who are not included in the health plan’s network.

preferred provider organization (PPO) - a type of managed care plan where members obtain services from a network of physicians who have nonexclusive arrangements with the managed care plan. Members also receive some benefit coverage when they obtain services from providers who are not in the plan’s network.

primary care physician (PCP) - a physician who devotes the majority of his/her practice to family or general medicine. In an HMO, the PCP serves as the gatekeeper who controls a patient’s access to care.

referral - written approval by your PCP for you to see a specialist.

specialist - a doctor to whom you may be referred to by your primary care provider for specialty health care services.

urgent care - a medical condition which, if not treated within 24 hours, could lead to serious impairment of bodily functions or serious dysfunction of any bodily organ or part.