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Glossary of Terms

Your charges for a medical visit.

The process by which an organization recognizes a provider, a program of study, or an institution as meeting predetermined standards.

Processing claims according to contract.

Administrative Adjustment
An account adjustment that represents the amount the institution is unable to collect due to billing policy or institutional error.

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.

Advance Directive
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.

A formal medical billing term that refers to insurance claims that haven't been paid or balances owed by patients overdue by more than 30 days.

Allowed Amount
Maximum amount on which payment is based for covered health care services.

Ambulatory Care
Health service provided without the patient be admitted. Also called outpatient care.

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.

Ancillary Services
Supplemental services, including laboratory, radiology, physical therapy and other similar services that are provided in conjunction with medical or hospital care.

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.

Authorization Number
A number stating that your treatment has been approved by your insurance plan.

Bad Debt
An amount owed that is considered uncollectible and/or is referred to an outside agency for further collection efforts.

Balance Bill
The patient's balance that is billed after the health plan, insurance company or Medicare have paid its approved amount.

Person coved by health insurance.

The health care items or services covered under a health insurance plan. Covered benefits and non-covered services are defined in the health insurance plan's coverage documents.

Billed Charges
The total charges that providers send to insurance companies/patients prior to any negotiated contracts or discounts being applied.

Birthday Rule
Used to determine primary and secondary coverage for children when two parents' have insurance coverage. The word "birthday" refers only to the month and day in a calendar year, not the year in which the person was born.

Case Management
An interdisciplinary team within the hospital, which helps you, receive the care you need, especially when you need preauthorized care from several services.

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

Your medical bill that is sent to the insurance company, for processing of payment. The information billed to your insurance carrier for services provided.

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

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 you own when you are unemployed.

A mechanism for identifying and defining medical services.

  • CPT – Current Procedural Terminology
  • HCPCS – HCFA Common Procedure Coding System
  • ICD-10 – International Classification of Diseases, 10th Edition

The cost-sharing portion of your bill you will have to pay. An arrangement by which the patient and insurance company share in the payment of a service. Co-insurance is usually a percentage of charges that takes effect after the yearly deductible amount has been met.

Coinsurance Days (Medicare)
Hospital Inpatient Medicare coverage from day 61 to day 90 of continuous hospitalization. The patient is responsible for paying for part of those days. After the 90th day, they enter their "Lifetime Reserve Days".

Concurrent Review
A utilization program to review medical care of patients currently hospitalized or under treatment. A case manager or review agent coordinates decisions regarding a patient's length of stay and discharge plans.

Contractual Adjustment
A portion of your bill that is reduced in accordance with the contract between UC San Diego Health and your insurance company.

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 set fee established by your insurance company for a specific type of visit.

Covered Benefit
A health service 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.

Covered Services
A health care service your insurance company agrees to pay a pre-established rate and/or percentage for.

The portion of eligible (covered) expenses that you must pay each year before coverage begins.

Persons designated in writing by the insurance company meeting the dependency tests as stipulated by the insurance policy. Dependency requirements can vary by policy and subscriber group. Examples of dependency requirements include the following:

  • Coverage for spouse if spouse is not eligible for coverage through his/her own employment.
  • Coverage for dependent children up to age 18 and continued coverage only if the child is enrolled full time as a student at an approved educational institution.

Description of Service
Tells what the doctor or hospital did for the patient.

Diagnosis Code
A code used for billing that describes the patient's illness.

Diagnosis Related Group (DRG)
A classification system currently in use for determining hospital payments based on patient diagnosis, complications or co-morbid conditions, need for surgery, age, sex, and discharge status. A fixed amount is paid for each discharged patient depending on the assigned DRG. Payment is generally independent of the length of stay and resources utilized.

Diagnostic Tests
Medically necessary test(s) and/or non-surgical procedures(s) ordered by a physician to determine if the patient has a certain condition or disease. Such diagnostic tools include radiology, laboratory, pathology services or tests.

Criteria that, if unmet, will cause an automated claims process system to "kick out" a claim for further investigation.

Electronic Claim
A digital representation of a medical bill generated by a provider or by the provider's billing agent for submission using telecommunication to a health insurance payer.

Electronic Data Interchange (EDI)
The automated exchange of data and documents in a standardized format. In health care, come common uses of this technology include claims submission and payment, eligibility, and referral authorization.

Electronic Remittance Advice
Any of several electronic formats for explaining the payments of health care claims.

Refers to medical procedure not immediately necessary, usually procedures that can be scheduled in advance.

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.

Eligibility Verification
A way hospitals determine whether the patient has insurance coverage for the services they will provide.

Evaluation and Management Services
Professional service provided by physicians for the purpose of diagnosing and treating diseases, and counseling and evaluation patients.

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.

Experimental Procedures
Any service or supply that is in the developmental stage, in the process of human or animal testing and/or considered by the payer as not proven effective.

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
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 and Medical Group relies on patient care revenues, commercial insurance, government programs, or direct patient payments.

Fiscal Intermediary (FI)
A Medicare agent that processes Medicare claims.

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.

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.

Global Period
A period in which all procedures have, either 0 day, 10 day or 90 day global periods. This period includes service(s) and charge(s) related to pre-operative evaluation (starting from 24 hours prior to the procedure, day before, or day of procedure) and post-operative evaluation(s), if applicable.

Group Number
A number the insurance company uses to identify the group under which the patient is insured.

The person financially responsible for paying the bill.

HCPC Codes
A coding system used to describe what treatment or services were provided to the patient.

Health Insurance Portability and Accountability Act. This federal Act sets standards for protecting the privacy of your health information.

Independent Practice Association (IPA)
An HMO model in which providers own and maintain independent offices. Providers are contracted with managed care companies for services at discounted or capitated rates, though they are usually allowed to accept fee-for-service patients as well.

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Lifetime Maximum
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.

Most policies have a maximum dollar amount that the insurance company will pay out over the life of the contract (lifetime maximum). In addition, there may be a per-year or per-illness maximum.

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.

Medical Group
Any partnership, association, or group of licensed health care providers working together in medical practice.

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.

Medically Necessary
Refers to services or supplies that are required to properly treat a specific medical condition. Services or supplies that are not considered medically necessary by insurance may be denied.

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.

Codes used in conjunction with CPT or HCPCS codes to indicate service changed in some way.

National Drug Code (NDC)
A medical code set maintained by the Food and Drug Administration that contains codes for drugs that are FDA approved. The Secretary of HHS adopted this code set as the standard for reporting drugs and biologics on standard transactions.

National Provider Identifier
A system for uniquely identifying all providers of health care services, supplies, and equipment.

A group of doctors, hospitals, and other health care providers that have a contract with an insurance company to provide services to its patients.

Non-Billable Service
Any service considered "incident to" a major service and "bundled into" the patient encounter under many insurance plans. Payment for such a service is included in the amount paid for the major service with which it is bundled.

Non-Covered Charges
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 Network
A provider who does not have a contract with your insurance company to provide services to you. You will pay more to see an out-of-network or non-preferred provider.

Out of Network Benefits
With most HMOs, a patient cannot have any services reimbursed if provided by a hospital or doctor who is not in the network. With PPOs and other managed care organizations, there may exist a provision for reimbursement of "out of network" providers. Usually this will involve higher co-pay or a lower reimbursement.

Out of Pocket
The portion of all medical bills for which the patient is responsible to pay before the insurance will cover all claims at 100%.

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 deductible, coinsurance, and co-payments for doctor visits and prescription drugs.

Participating Provider
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.

Patient Liability
The dollar amount that an insured is legally obligated to pay for services rendered by a provider. These may include co-payment, coinsurance, deductible, and payments for non-covered services.

Payment Arrangements
The monthly amount the patient or guarantor agrees to pay towards their outstanding bill.

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.

A program created by the Affordable Care Act to provide a health coverage option if you were uninsured for at least six months, had a pre-existing condition, and were denied coverage (or offered insurance without coverage of the pre-existing condition) by a private insurance company. This program provided coverage until 2014, when access to affordable health insurance choices became available through the Health Insurance Marketplace.

Point of Service (POS) Plan
A type of managed care health insurance plan that combines characteristics of both the HMO and the PPO.

Policy Number
A number that your insurance company gives you to identify your policy.

Clinical validation that services or procedures are appropriate and approved as a treatment protocol for a patient's condition or diagnosis.

Pre-Certification Number
This number represents the agreement by the insurance company that the services have been approved. It is not a guarantee of payment.

Pre-Existing Condition
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 sum a person pays to an insurance company on a regular (usually monthly) basis to receive health insurance.

Preventive Care
Care rendered by a physician to promote health and prevent future health problems for a member who does not exhibit any symptoms. Examples are routine physical examinations and immunizations.

Primary Insurance
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 Physician (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).

Primary Plan
A plan whose benefits for a person's health care coverage must be determined without taking the existence of any other plan into consideration. In other words, the primary plan must pay or provide its benefits as if a secondary plan did not exist.

Prior Authorization
A formal approval obtained from the insurance company prior to the delivery of medical services.

Professional Component
The part of the relative value or fee for a procedure that represents physician work.

A hospital or physician who provides medical care to the patient.

Provider Network
The set of providers contracted with a health plan to provide services to the members.

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A physician’s medical order for services or consultation to be provided by another provider, usually a specialist.

The money compensation for medical services provided by the provider.

Relative Value Unit (RVU)
The unit of measure for a relative value scale. RVUs must be multiplied by a dollar conversion factor to become physician practice payment amounts.

Remittance Advice (R/A)
The document attached to a processed claim that explains the information regarding coverage and payment on a claim. Can also be known as an EOB.

Resource-Based Relative Value Scale (RBRVS)
A schedule of values assigned to health care services that give weight to procedures based upon resources needed by the provider to effectively deliver the service or perform the procedure.

Responsible Party/Guarantor
The person responsible to pay the bill.

Revenue Code
Medical billing terminology for a 3-digit number used on hospital bills to tell the insurer where the patient was when they received treatment, or what type of item a patient received.

Secondary Coverage
Health plan that pays costs not covered by primary coverage under coordination of benefit rules.

Secondary Insurance
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.

Second Opinion
The option or recommendation to visit another physician or surgeon regarding diagnosis, course of treatment or having specific types of elective surgery performed.

Second Surgical Opinion (SSO)
Included among the feature of Medical Management programs, SSO provides coverage for a second opinion from a qualified surgical specialist to group members seeking elective surgery. Mandatory SSO requires that group members seek the second opinion.

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 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.

Service Area
The geographic area in which a health plan delivers health care through a contracted network of participating providers.

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.

Technical Component
The part of the relative value or fee for a procedure that represents the costs of doing the procedure but excludes physician work.

Third Party Liability (TPL)
If you are involved in an accident, you may have coverage through your automobile insurance or other coverage to help pay for your hospital or physician bill.

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.

A coding inconsistency that involves separation a procedure into parts and charging for each part rather than using a single code.

Urgent Care
A condition that requires prompt medical attention, but is not a threat to life or limb.

Usual, Customary, and Reasonable (UCR)
Health insurance plan reimbursement methodology that limits payment to the lower billed charges, the provider's customary charge, or the prevailing charge for the service in the community.

Utilization Management
The evaluation of medical necessity, efficiency and/or appropriateness of health care services and treatment plans.

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Well Baby/Well Child Care
Routine care, testing, checkups and immunizations for a generally healthy child.

Wellness Program
A health management program which incorporates the components of disease prevention, medical self-care and health promotion.

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