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Advanced Beneficiary Notice (ABN)
A notice the hospital or doctor gives you before you are treated, which specifies that Medicare will not pay for some treatments or services. The notice is provided to you so that you can decide whether or not to have the treatment and the cost associated to that treatment.
Written ahead of time, a health care advance directive is a written document that says who you want to make medical decisions if you lose the ability to make decisions for yourself.
Amount Not Covered
What your insurance company does not pay according to your individual policy benefits. It includes deductibles, coinsurances, and charges for non-covered services.
A process by which you, your doctor or, your hospital can object to your health plan’s decision not to pay for physician-ordered services.
Applied to Deductible
Portion of your bill, as defined by your insurance company, that you owe your doctor or hospital.
Assignment of Benefits
The transfer of the right for reimbursement from the insured person to a health care provider so that payment of plan benefits can be paid directly to the provider.
A number stating that your treatment has been approved by your insurance plan.
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An interdisciplinary team within the hospital, which helps you, receive the care you need, especially when you need preauthorized care from several services.
Your medical bill that is sent to the insurance company, for processing of payment. The information billed to your insurance carrier for services provided.
Coinsurance or Co-Payment (co-pay)
The cost-sharing portion of your bill that you will have to pay. An arrangement by which the patient and insurance carrier share in the payment of a service. Co-insurance takes effect after the approved deductible amount has been met.
Coordination of Benefits (COB)
The determination of benefits payable under more than one group health insurance plan so the insured’s total benefits do not exceed 100 percent of the medical benefits.
A health service that is included in your health plan and that is paid for either partially or fully.
The portion of eligible (covered) expenses that you must pay each year before coverage begins.
Eligible Payment Amount
Medical services for which an insurance company has decided is eligible for payment. This amount still includes the patient cost-sharing portion.
Evidence of Coverage (EOC)
A written guide from your health plan that explains that the plan does and does not cover and the rules you must follow for getting care.
Explanation of Benefits (EOB)
The notice provided to the insured by an insurance company explaining the fees charged and the amount paid on each charge. It also explains the patient responsible amount.
Financial Counselors are part of the Patient Access / Admissions team who are dedicated to helping patients and physicians determine sources of reimbursement for hospital services. As a private, non-profit institution, UC San Diego Health System and Medical Group relies on patient care revenues, commercial insurance, government programs, or direct patient payments.
Flexible Spending Account (FSA)
A short-term savings account that allows you to set aside pre-tax income and use it to pay for health care expenses throughout the year.
The person financially responsible for paying the bill.
Health Insurance Portability and Accountability Act. This federal Act sets standards for protecting the privacy of your health information.
The Health Insurance Lifetime Maximum of your plan is the total amount of money the insurance company will pay for the entire time you have coverage under that plan. Once you reach that amount, your plan will not pay for any more of your medical expenses.
Medi-Cal is California's Medicaid program, a medical assistance program for low-income and/or disabled residents that is funded by the state and federal government. If you are covered under this program, please provide an eligibility card or other proof of eligibility for each month of service.
Medi-Cal Managed Care
Medi-Cal Managed Care Division administers, monitors, and provides oversight of the contracts for the Medi-Cal program. It utilizes a “network of providers” to manage your health care, similar to an HMO plan in the private sector.
Medical Record Number
The number assigned by your doctor or hospital that identifies your individual medical record. All of your individual days of service are filed under the same medical record number.
A social insurance program for individuals who are 65 years or older and younger individuals with a disability as well as those with end stage renal disease.
Medicare Part A
Usually referred to as Hospital Insurance, it helps pay for inpatient care in hospital and hospices, and some skilled nursing costs.
Medicare Part B
This pays for doctor’s services, outpatient services and care of other medical services not paid for by Medicare Part A.
Medicare Part C/ Medicare Advantage Plans
This is also known as Medicare HMO plans. The Medicare Advantage plans work like a private HMO. You must use doctors and hospitals that are within your plan’s network and you may need prior authorization for certain services. Secure Horizons and HealthNet Seniority Plus are types of Medicare HMO’s.
Medicare Part D
Your Part D benefit is your prescription drug plan that you purchase separately from your other Medicare part A and B. The part D plan is included in you Medicare Advantage/HMO plans.
Medicare supplemental insurance that, depending upon your policy, pays for some services not covered by Medicare A or B including deductible and coinsurance amounts.
Charges for medical services denied or excluded by your insurance plan. You may be billed for these services.
Non-Participating Provider/Out-of-Network Provider
A doctor, hospital or other health care provider that is not part of an insurance plan's health care network.
Out of Pocket Maximum
The yearly out-of-pocket maximum is the highest or total amount your health insurance company requires you to pay towards the cost of your health care per year. Out-of-pocket expenses are what you pay for health-related services above and beyond your monthly premium. Depending on your health plan, these expenses may include an annual deductable, coinsurance, and copayments for doctor visits and prescription drugs.
A doctor or hospital that has agreed to accept a pre-negotiated rate as payment for covered services as payment in full, minus your deductibles, coinsurance or co-pay amounts.
Preferred Provider Organization
Health coverage that allows the member to direct his/her own health care and offers more flexibility by allowing visits to out-of-network professionals. These types of plans generally have higher costs to the policy holder depending on whether they use in-network or out-of-network providers.
Also known as the “Pre-Existing Insurance Plan" for patients who need to purchase a private insurance policy and have a known pre-existing condition. The plan is supplemented by the Federal Government and therefore is an affordable PPO insurance plan. Each State has their own requirements as to who qualifies for the program. Basic requirements include: un-insured for the last 6 months, you must be a resident in the state you are applying in, you are a legal resident or Citizen of the United States and you must have a pre-existing condition. Additional information about California PCIP can be found at www.pcip.ca.gov or at 1-877-428-5060.
Point of Service (POS) Plan
A type of managed care health insurance plan that combines characteristics of both the HMO and the PPO.
A number that your insurance company gives you to identify your policy.
A health condition or medical problem that you already have before you sign up to receive insurance. Some health insurers may not pay for health conditions you already have for a pre-determined length of time.
The insurance company that is responsible for paying your claim first. If you have another insurance company, it is referred to as “secondary insurance.”
Primary Care Provider (PCP)
The primary care physician is responsible for all general medical care of patients and makes referrals to specialists for tertiary care when medically appropriate. A PCP can be an internist, pediatrician, family physician, or OB/GYN).
A physician’s medical order for services or consultation to be provided by another provider, usually a specialist.
Secondary coverage, usually as a result of being covered under someone else's (such as a spouse) health insurance plan, provides reimbursement for medical expenses after available coverage is utilized through the primary plan. A secondary insurance may also pay for medical services if the primary insurance denies coverage.
If you don’t have insurance or if you’re seeking care that is not covered by your insurance plan, you are considered a self-pay patient. UC San Diego Health System offers a discount to all self-pay patients. If you are unable to afford the discounted rate, you may qualify for government assistance programs or our charity care assistance program. Financial Counselors are available to discuss your options and offer assistance in the financial planning for your medical care.
Share of Cost (SOC – Medi-Cal)
Medi-Cal may require certain patients to pay a monthly deductible before they become eligible for Medi-Cal benefits. Share of cost refers to the amount of health care expenses a patient must pay for each month before their Medi-Cal benefits begins. Once a person’s health care expenses reach that predetermined amount, Medi-Cal will pay for any additional covered benefits for that month. Share of cost is an amount that is paid to the provider of health care services, not to the state. The specific amount is determined by the County and varies by each individual.
An individual who is enrolled for benefits with an insurance company and is responsible for the health insurance policy.
Supplemental Insurance Company
An additional insurance policy that handles claims for deductible and coinsurance reimbursement. This applies to Medicare recipients.
A TAR is a Treatment Authorization Request. The TAR is used to get authorization from Medi-Cal for your services.
Third Party Liability Form
This is a form required by your insurance company requesting information about an injury or condition that may have been caused by another’s negligence (i.e. automobile accident, slip and fall). Upon receipt of the TPL form, you should complete, sign and return it to your insurance company to avoid delays in payment processing or a denial.
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