Glossary of Terms

The following is a list of frequently used billing and insurance terms as defined by Centers for Medicare and Medicaid Services (CMS). Please do not hesitate to contact your CMG practice with questions about your bill. A CMG billing representative will be happy to assist you.

Accessibility of Services: The ability to get medical care and services when they are needed.

Advance Beneficiary Notice (ABN): A notice that a provider or facility should give a plan beneficiary to sign in the following cases: Your doctor gives you a service that he or she believes that the plan may not consider medically necessary; and your doctor gives you a service that they believe the plan will not pay for. The ABN may also be referred to as a waiver.

Affiliated Provider: A health care provider or facility that is contracted and paid by a health plan to give service to plan members.

Allowed Charge: Contracted rate for individual charges determined by a carrier for a covered medical service or supply.

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

Ambulatory Surgical Center: A facility other than a hospital that performs outpatient surgery.

Appeal Process: The process you use if you disagree with any decision about the health care process, service or payment. If the participant is in a managed care plan, they can file an appeal if the plan will not pay for, or does not allow or stops a service that the patient or provider believes should be covered or provided. The plan may have special protocols to follow in order to file an appeal. See the plan's membership materials or contact the plan for details about appeal rights and procedures.

Approved Amount: The negotiated amount established in the agreement between the provider and plan to cover a particular service.

Assignment: A process whereby a plan or payor, pays its share of the allowed charge directly to the physician or supplier.

Beneficiary: The person who is eligible to receive benefits through a health insurance program.

Benefits: The money or services provided and covered under an insurance policy.

Board Certified: This means a doctor has special training in a certain area of medicine and has passed an advanced exam in that area of medicine. Both primary care doctors and specialists may be board-certified.

Capitation: A provider payment method used by health plans. The provider is paid a set amount per member per month. The provider receives the same amount regardless of how many times the member uses his or her services.

Carrier: An entity that may underwrite or administer a range of health benefit programs. May refer to an insurer or a managed health plan.

Cash Basis: The actual charge of the service when the service was performed.

Centers for Medicare and Medicaid Services (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. CMS is responsible for oversight of HIPAA administrative simplification transaction and code sets, health identifiers, and security standards. CMS also maintains the HCPCS medical code set and the Medicare Remittance Advice Remark Codes administrative code set.

Claim: A claim is a request for payment for services and benefits received. Information is customarily submitted by a provider to establish that medical services were provided to a covered person.

CMS-1500: The uniform professional claim form.

Coinsurance: The co-payment a member makes based on a percentage of the costs of the medical services received, usually around 10 to 20 percent. Coinsurance is usually found in indemnity, fee-for-service and PPO plans, often along with deductibles.

Confidentiality: The ability to speak with the provider or representative without disclosing the information to an uninterested party.

Consolidated Omnibus Budget Reconciliation Act (COBRA): The acronym for the Consolidated Omnibus Reconciliation Act, a federal law permitting many people who lose eligibility under a group health plan to continue that coverage without a lapse.

Coordination of Benefits: A process that applies when determining which plan or insurance policy will pay first if multiple policies exist.

Copayment: The set amount, usually $5 to $25, an HMO member pays the provider for services. Unlike coinsurance, this amount is not based on a percentage of the actual cost of services, but is pre-determined.

Covered Services: A health service or item that is included in the benefit plan, and that is paid for either partially or fully.

Covered Charges: Services or benefits for which a health plan makes either partial or full payment.

Covered Entity: Under HIPAA, this is a health plan, a health care clearinghouse, or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction.

Deductible: The annual amount payable by the beneficiary for covered services before Medicare makes reimbursement. See also "Inpatient hospital deductible."

Deductible (Medicare): The dollar amount that a member must pay for medical services before health plan coverage begins.

Demographic Data: Data that describe the characteristics of the beneficiary and/or guarantor. Demographic data include but are not limited to age, sex, race/ethnicity, and primary language.

Department of Health and Human Services (DHHS): DHHS administers many of the "social" programs at the Federal level dealing with the health and welfare of the citizens of the United States. It is the "parent" of CMS.

Determination: A decision made to either pay in full, pay in part, or deny a claim. See also Initial Claim Determination.

Diagnosis: The name for the health problem the patient presented or was treated for during an encounter or communication with the provider.

Diagnosis Code: ICD-9-CM diagnosis code sets that correspond to conditions that (co)existed at the time of treatment.

Disclosure: Release or divulgence of information by an entity to persons or organizations outside of that entity.

Disenroll: Ending health care coverage with a health plan.

Durable Medical Equipment (DME): Medical equipment that is ordered by a provider for patient use outside of the facility; which can withstand repeated use; is not disposable; is used to serve a medical purpose and is appropriate for the home.

Effective Date: See Eligibility Date.

Eligibility: Refers to the process whereby an individual is determined to be eligible for health care coverage through their plan.

Eligibility Date: The date on which health plan coverage begins.

Enroll: To join a health plan.

Explanation of Benefits: A coverage statement that is sent to the patient and/or provider when a claim is filed. The statements informs what the provider billed for, the plan's approved amount and how much they paid.

Fee Schedule: A comprehensive list of all services provided and their respective charge.

Fee-for-Services: A method of paying the provider for service or treatment based on the fee schedule.

Formulary: A list of certain drugs and their proper dosages. In some health plans, doctors must order or use only drugs listed on the health plan's formulary.

Gatekeeper: In a managed care plan, this is another name for the primary care doctor. This doctor gives you basic medical services and coordinates proper medical care and referrals.

Grievance: A complaint about the way health care service, process or payment were handled.

Guarantor: The person responsible for payment of rendered services. The guarantor is customarily the person bringing the patient in for treatment. This person is not necessarily the same as the subscriber.

Health Care Provider: A person who is trained and licensed to give health care. Also, a place licensed to give health care. Doctors, nurses, hospitals, skilled nursing facilities, some assisted living facilities, and certain kinds of home health agencies are examples of health care providers.

Health Insurance Portability and Accountability Act (HIPAA): HIPAA is the Health Insurance Portability and Accountability Act signed into law in 1996. An Administrative Simplification section in the law requires adoption of standards for security, privacy and electronic healthcare transactions.

Health Maintenance Organization (HMO): A legal corporation that provides health care in return for pre-set monthly payments. For most HMOs, members must use the physicians, hospitals and other health care professionals in the HMO's network in order to be covered for their care. There are several models of HMO, including the Staff Model, Group Model, IPA Model, Direct Contract Model and Mixed Model.

Health Plan: An entity that assumes the risk of paying for medical treatments, i.e. uninsured patient, self-insured employer, payer, or HMO.

Indemnity: This is a form of coverage offered by most traditional insurers. An indemnity plan reimburses the patient directly medical costs regardless of who provided them.

Insurer: An insurer of a GHP is an entity that, in exchange for payment of a premium, agrees to pay for GHP-covered services received by eligible individuals.

Interest: A payment for the use of money during a specified period. May also be a form of penalty for non-timely reimbursement.

Letter of Request: A formal request from the requestor detailing informational needs and purposes.

Managed Care: A term originally coined to refer to the prepaid health care sector (e.g., HMOs) where care is provided under a fixed budget and costs are supposedly capable of being "managed." Now the term also can refer to PPOs and some forms of indemnity insurance coverage that incorporate preadmission certification and other utilization controls.

Managed Care Organization (MCO): A health plan that provides coordinated health care through a network of primary care physicians and hospitals for pre-set monthly payments.

Medicaid: A health plan that provides coordinated health care through a network of primary care physicians and hospitals for pre-set monthly payments. A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid.

Medicaid MCO: A Medicaid MCO provides comprehensive services to Medicaid beneficiaries, but not commercial or Medicare enrollees.

Medically Necessary: Services or supplies that: are proper and needed for the diagnosis, or treatment of your medical condition; are provided for the diagnosis, direct care, and treatment of your medical condition; meet the standards of good medical practice in the local area; and are not mainly for the convenience of the patient or provider.

Medigap Policy: A Medicare supplement insurance policy sold by private insurance companies to fill "gaps" in Original Medicare Plan coverage.

Member: See Subscriber.

Military Treatment Facility: A medical facility operated by one or more of the Uniformed Services.

National Committee for Quality Assurance (NCQA): A non-profit organization that accredits and measures the quality of care in health plans. NCQA does this by using the Health Employer Data and Information Set (HEDIS) data reporting system.

Network: A group of health care providers and suppliers of other goods and services to provide service to patients.

Non-covered Service: The service (a) does not meet the requirements of a benefit and (b) may not be considered reasonable and necessary.

Non-participating Physician: A provider that is not contracted or accepts assignment with a particular plan.

Nurse Practitioner: A nurse who has advanced training and assists physicians by providing care to patients in their absence. Must stay within the scope of their abilities. NPs may also be considered providers.

Office: Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, state or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.

Open Access: A term describing a member's ability to self-refer for specialty care. These models allow patients to see a participating specialist without a referral.

Out of Network: Services a member receives from a health care provider who does not belong to the member's health plan's network of selected and approved physicians and hospitals. If the services were not pre-approved by the health plan, the member may have to pay for all or most of that care him/her self. Exceptions are usually made for extreme emergencies or urgent care needed when traveling away from home.

Out of Pocket Costs: Health care expenses that the patient is responsible for as they are not fully or partially covered by their plan.

Outpatient Care: Medical or surgical care that does not include an overnight hospital stay.

Participating Physician or Supplier: A provider who agrees to accept assignment on the claims. These providers should only initially bill for the patient's cost share amount.

Payer: In health care, an entity that assumes the risk of paying for medical treatments. This can be an uninsured patient, a self-insured employer, a health plan, or an HMO.

Point of Service (POS): A health plan option that allows members to use either a network provider or a non-network provider at their discretion. If a member chooses to go out of network, they may pay a higher co-pay or deductible.

Pre-existing Condition (Medigap Policy): A medical condition the patient you had before the date that a new insurance policy starts.

Preferred Provider Organization (PPO): A network of doctors and hospitals that provide health care services at a pre-negotiated lower price. Members receive better benefits when they use network providers, but have the option to used out-of-network providers for higher out-of-pocket costs.

Premium: The predetermined monthly membership fee a subscriber or employer pays for health plan coverage.

Preventive Care: Care designated to keep the patient healthy or to prevent illness, such as colorectal cancer screening, yearly mammograms, and flu shots.

Primary Care: A basic level of care usually given by doctors who work with general and family medicine, internal medicine (internists), pregnant women (obstetricians), and children (pediatricians). A nurse practitioner (NP), a State licensed registered nurse with special training, can also provide this basic level of health care.

Primary Payer: An insurance policy, plan, or program that pays first on a claim for medical care.

Procedure: Something done to fix a health problem or to learn more about it. For example, surgery, tests, and putting in an IV (intravenous line) are procedures.

Protected Health Information (PHI): Individually identifiable health information transmitted or maintained in any form or medium, which is held by a covered entity or its business associate. Identifies the individual or offers a reasonable basis for identification. Is created or received by a covered entity or an employer. Relates to a past, present, or future physical or mental condition, provision of health care or payment for health care.

Provider: Any healthcare provider such as hospital, physician, non-physician provider, laboratory, etc. that provides medical services.

Referral: The formal process that gives a health plan member authorization to receive care from a provider other than his or her primary care provider. Without a referral, such care may not be covered.

Referral Authorization: The verbal or written approval of a referral request that gives a health plan member authorization to receive care from a provider outside the plans established network.

Referral Physician: The physician a patient has been referred to by his or her primary care provider.

Secondary Payer: An insurance policy that supplements the primary coverage and pays second on a claim for medical care.

Service Area: The geographic area serviced by the health plan as approved by the state regulatory agencies and/or detailed in the certification of authority.

Specialist: A doctor who treats only certain parts of the body, certain health problems, or certain age groups.

Subscriber: A participant in a health plan (enrollee or eligible dependent) who makes up the plan's enrollment. Also used to describe an individual specified within the policy who may or may not receive services according to the benefit limits.

Termination Date: The date that an agreement expires; or, the date that a subscriber and/or member ceases to be eligible.

Third Party Administrator (TPA): An organization that administers health care benefits-including claims review, claims processing, etc.-usually for self-insured employers.

Transaction: The exchange of information between two parties to carry out financial or administrative activity.

Third Party Administrator (TPA): An organization that administers health care benefits-including claims review, claims processing, etc.-usually for self-insured employers.

TRICARE: TRICARE is the health care program for active duty members of the military, military retirees, and their eligible dependents. TRICARE was called CHAMPUS in the past.

Urgently Needed Care: Care sought after or received for a sudden illness or injury that needs medical care right away, but is not life threatening.

Utilization Summary Data: Data that are aggregated by the capitated managed care entity (e.g. the number of primary care visits provided by the plan during the calendar year).

Withhold: A financial incentive used to encourage efficient care. It is the portion of the monthly capitation payment that is withheld if the physician exceeds utilization norms.