Term | Definition |
EDI | Electronic Data Interchange
Involving the computerized transfer of health care information between 2 parties for specific purposes. |
NPI | National Provider Number
# assigned to Providers by CMS for submitting insurance claims. |
Supporting Claim Documentation | Documentation such as charts notes, labs, etc., required by many insurance companies when filing a claim. |
Past Filing Limits | Most carriers allow claims to be filed up to 1 year after the service has been provided, but for some it's 90 days. PFL claims will be rejected. |
Medicare | Federal Health Insurance program for people over age 65. |
Medicare Part A | Hospital Insurance that is automatic if you receive Soc Sec benefits. |
Medicare Part B | Fee-for-service, optional program that requires insured to pay income-based premiums. |
Medicare Part C | Medicare Advantage Managed Care |
Medicare Part D | Prescription Drug Coverage (limited) |
WC | Worker's Compensation insurance covers employees injured in the workplace or suffering from a workplace-related illness. |
Tri-Care | (formerly CHAMPUS) Government insurance program for active duty and retired military personnel. |
CMS | Centers for Medicare and Medicaid Services |
ABN | Advanced Beneficiary Notice (or waiver) that must be signed by Medicare patients. Patients agree to pay for specified procedure that might not be covered by Medicare. |
Out-of-Pocket Expenses | Patient's responsibility including deductibles and co-pays and amount that is left after insurance covers. |
Primary Payer | 1st payer, usually responsible for more money or higher charge |
Secondary Payer | MSP rules (Medicare Secondary Payer) - where the Primary Insurance is Primary and Medicare is secondary (patient cannot choose). |
Physician Fee Schedule | The amount the Provider charges for each procedure performed. Cannot charge more or less based on the insurance or patient. |
VOB | Verification of (Insurance) Benefits
Verifying insurance coverage either by calling (in-person) of by computer program. Usually is completed before the appt. |
Pre-Authorization | Contacting the insurance company to obtain permission for a procedure. |
COB | Coordination of Benefits
Determining the Primary / Secondary insurances |
Co-Pay | Fixed $ amount that the patient pays |
Co-Insurance | Fixed % that the patient pays |
Deductible | Monetary amount patient must pay before insurance kicks in. |
CMS-1500 | Uniform billing format used for medical claims. |
Medicaid | MCD - Health benefit program for low-income patients. ALWAYS billed 2nd. |
PCP | Primary Care Provider / Gatekeeper who arranges for care / specialists / hospitalizations. |
CHAMPVA | Insurance through government for disabled veterans. |