A

• Accept Assignment
  Provider has agreed to accept the insurance company allowed amount as full payment for the covered services.

• Adjudication
  The final determination of the issues involving settlement of an insurance claim.

• Allowed Amount
  The amount of the billed charge the insurance company deems payable.

• AMA (American Medical Association)
  www.ama-assn.org

• Ambulatory Care
  Any medical care delivered on an outpatient basis.

• Ancillary Services
  Services including laboratory, radiology, home health, and skilled nursing facilities.

• Assignment of Benefits Authorization
  The patient or guardian signs the Assignment of Benefits form so that the medical provider will receive the insurance payment directly.

• Authorization / Prior Authorization
  Approval from insurance company required for the patient to receive services. May be necessary before hospital admission or services from non-HMO providers.

B

• Beneficiary
  Person covered by health insurance or Medicare benefits.

C

• Capitation
  A payment model where the physician is paid a set amount per member per month to provide care to a specific group.

• CCS (California Children Services)
  A state program for children with certain diseases or health problems.

• CHDP (Child Health and Disability Prevention Program)
  Preventive health program for low-income children and youth in California.

• Claim Response Report
  Palmetto GBA’s GPNet Claim Acceptance Response Report. Includes submission outcomes and error messages.

• Clearinghouse
  A company that receives and retransmits electronic claims data between providers and payers.

• CMS (Centers for Medicare & Medicaid Services)
  Formerly HCFA. Oversees HIPAA standards, code sets, and identifiers.

• CMS 1450 (UB-04)
  Institutional billing form (formerly UB-92).

• CMS 1500
  Standard form used for provider billing.

• COB (Coordination of Benefits)
  Determines payment responsibilities when a patient has multiple insurance plans.

• COBRA (Consolidated Omnibus Budget Reconciliation Act)
  Temporary continuation of health coverage after employment ends.

• Contractual Adjustment
  The part of a charge the provider must write off due to payer contracts.

• Co-Pay
  Fixed amount the member must pay out-of-pocket.

• CPT Code (Current Procedural Terminology)
  5-digit code describing medical services and procedures.

D

• Deductible
  Amount a member pays before insurance coverage begins.

• DHS (Department of Health Care Services, California)
  www.dhcs.ca.gov

• Diagnosis Code
  ICD-9 code describing an illness or condition.

• DME (Durable Medical Equipment)

• DOS (Dates of Service)
  The date(s) a patient received care.

E

• EDI (Electronic Data Interchange)

• EFT (Electronic Funds Transfer)
  Paperless system for electronic fund transfers.

• EIN (Employer Identification Number)
  Also known as Tax Identification Number (TIN).

• EMR (Electronic Medical Records)

• EOB (Explanation of Benefits)
  Statement explaining how a claim was processed.

• EPSDT (Early and Periodic Screening, Diagnosis, and Treatment)
  Medi-Cal program for individuals under 21.

• ERA (Electronic Remittance Advice)
  Electronic version of the EOB; also called an 835 file.

F

• Fee for Service
  Payment model for individual medical services rendered.

• Fee Schedule
  List of CPT codes and allowable charges.

• Formulary
  List of drugs covered by an insurance plan.

G

• GPNet
  The EDI gateway for Palmetto GBA.

H

• HCPCS (Healthcare Common Procedure Coding System)
  Codes for medical procedures, aligned with CPT.

• HIPAA (Health Insurance Portability and Accountability Act)
  Federal law protecting patient health information.

• HL7 (Health Level Seven)
  Data exchange standard for medical systems.

• HMO (Health Maintenance Organization)
  Insurance model offering care through a network of providers.

I

• ICD-9 (International Classification of Diseases)
  Diagnosis coding system.

• IPA (Independent Practice Association)
  Group of physicians contracted with HMO plans.

• IVR (Interactive Voice Response)
  Automated Palmetto GBA system for claim and eligibility info.

J

• Jurisdiction 1
  Includes California, Hawaii, Nevada, Guam, American Samoa, and Northern Mariana Islands.

M

• MAC (Medicare Administrative Contractor)

• Medical Necessity
  Services must be necessary for treatment and not cosmetic or experimental.

• Medi-Cal
  California’s Medicaid program.
  www.medi-cal.ca.gov

• Medicare
  Federal program for individuals 65+ and some with disabilities.
  www.medicare.gov

• Medigap
  Private insurance to cover costs not paid by Medicare.

• Modifier
  Code added to a CPT code to indicate service alterations.

• MSP (Medicare Secondary Payer)

N

• N/C (Non-Covered Charge)
  Procedure not covered by insurance.

• NPI (National Provider Identifier)
  10-digit unique identifier for providers.

P

• Palmetto GBA
  Medicare contractor for Jurisdiction 1.
  www.palmettogba.com/J1B

• Participating Provider
  A provider who accepts a contracted rate from a health plan.

• PCP (Primary Care Physician)
  Main doctor responsible for a patient’s overall care.

• POS (Point of Service)
  Insurance plan allowing access to providers with or without a referral.

• PPO (Preferred Provider Organization)
  Insurance model with a network of discounted providers.

• Procedure Code
  CPT or HCPCS code used to describe a medical service.

• PTAN (Provider Transaction Access Number)
  Legacy Medicare number.

R

• RA (Remittance Advice)
  Document showing claim payment or denial details.

• Referral
  Approval from a PCP to see a specialist or receive services.

• Responsible Party
  Individual responsible for a patient's medical bill.

S

• Secondary Insurance
  Insurance that covers costs not paid by the primary plan.

• Skilled Nursing Facility
  Institution providing high-level medical care.

• SOF (Signature on File)

• Supplemental Insurance
  Additional insurance for deductibles, coinsurance, etc.

• Subscriber
  Policyholder (employee or individual).

T

• TAR (Treatment Authorization Request)
  Pre-treatment approval required by insurers.

• TCXMED Support
  Internet software or hardware support provided by the staff of TCXMED Computer Systems, Inc.

• Term Date
  End date of insurance coverage.

• TIN (Tax Identification Number)
  Same as EIN.

• TOS (Type of Service)
  Describes the category of the provided service.

• TTY (Teletypewriter)
  Communication device for the hearing impaired.

U

• UPIN (Provider Unique Personal Identification Number)
  Discontinued as of May 23, 2008.

• Untimely Submission
  Claims submitted after insurer’s deadline may be denied.

X

• XPrint
  Terminal emulator enabling printing from the Legacy Medical Billing system.

• XTerm
  Terminal emulator for connecting to the Legacy Medical Billing system.