Copay – A predetermined flat fee that an individual must pay for medical services. This payment is not usually subject to the deductible. There may be separate copays for different services.
Coinsurance – A specified percentage of medical expenses that an individual must pay after the deductible (if any) has been met.
COB (Coordination of Benefits) – This is the process by which a health insurance company determines if it should be the primary or secondary payer of medical claims for a patient who has coverage from more than one health insurance policy.
COBRA – The Consolidated Omnibus Budget Reconciliation Act (COBRA). When you lose job-based coverage, your former employer may offer you COBRA continuation coverage. This may allow you to temporarily keep health coverage until you get other health coverage, whether through a new job or another source. Eligibility for COBRA plans does not always run active in our system, and a phone call to insurance may be needed to verify your coverage.
Cosmetic - Something that is deemed by either the provider or insurance as not medically necessary.
CPT – short for Current Procedural Terminology. Any service provided to a patient (evaluation, test, surgery, etc.) has a corresponding CPT code. These codes are defined and mandated by the American Medical Association.
Deductible – A fixed dollar amount during a benefit period (usually a year) that an individual pays before the insurance plan starts to make payments for covered medical expenses.
EOB – An Explanation of Benefits (EOB) is a statement from your health insurance company that details how much they paid for a medical service and how much you still owe. It's not a bill, but it helps you understand what your insurance covers and how much you'll pay. An EOB may also be known as EOP (Explanation of Payment), Summary Notice, or Remittance Advice.
Fee Schedule – the value assigned to a CPT, determined by a specific insurance company’s contract. This is also referred to as the “allowable amount”. Excluding certain circumstances, providers must accept an insurance company’s fee schedule and cannot bill the patient beyond the allowable amount pre-determined by an insurance company. Fee schedules are unique to each insurance company – some insurances can even have several different fee schedules.
Good Faith Estimate – A good faith estimate (GFE) is a list of expected charges before you get health care items or services (procedures, supporting care) from a provider or facility. The good faith estimate isn't a bill. You're only given one if you don't have insurance or aren’t using insurance to pay for your care. See our Self-Pay Patients page for more information regarding your rights.
HIPAA - The US Health Insurance Portability and Accountability Act (HIPAA), enacted in 1996, was established to safeguard patient privacy and secure health information. HIPAA sets strict standards for managing, transmitting, and storing protected health information. HIPAA applies to healthcare providers, insurers, and other organizations handling patient data, mandating safeguards to prevent unauthorized access or misuse of sensitive information. HIPAA regulations uphold patients' rights to confidentiality and empower them to control the disclosure of their health information.
ICD – short for International Classification of Diseases. These are also known as “diagnosis codes”. Any illness, injury, or condition has a corresponding ICD code. Just like CPT codes, ICD codes are defined and mandated by the American Medical Association.
Medical necessity is defined as accepted health care services and supplied provided by health care entities, appropriate to the evaluation and treatment of a disease, condition, illness or injury and consistent with the applicable standard of care. If something is not medical necessary, it is considered to be “cosmetic”.
Medigap – Medicare supplemental insurance sold by private insurance companies to fill “gaps” in original Medicare coverage.
Network – Groups of physicians, hospitals and other health care providers contracted with a health plan to offer care at negotiated rates.
Preferred Provider Organization (PPO) – A health insurance plan where coverage is provided to individuals through a network of selected health care providers. The insured may go outside the network but will incur larger costs in the form of higher deductibles and coinsurances, or non-discounted charges from the providers.
Health Maintenance Organization (HMO) – A health insurance plan where individuals must choose a primary care physician (PCP) who coordinates all care and makes referrals to any specialists that may be required. Individuals MUST use in network providers; there is no coverage for care received from a non-network provider except in an emergency situation.
Exclusive Provider Organization (EPO) – A more restrictive type of PPO where individuals MUST use in network providers; there is no coverage for care received from a non-network provider except in an emergency situation.
Point-of-Service (POS) – A POS plan is an “HMO/PPO” hybrid; sometimes referred to as an “open-ended” HMO when offered by an HMO. POS plans resemble HMOs for in-network services, but for all services received outside of the network payment is made based on a fee schedule or usual and customary charges.
Network Provider – Physicians, hospitals or other providers of medical services that have agreed to participate in a network, to offer their services at negotiated rates, and to meet other negotiated contractual provisions. Also referred to as “participating provider.”
Notice of Non-Covered Service waiver that is similar to the Medicare ABN for patients with commercial insurance plans for similar procedures that may not be covered.
Out-of-Network – Health care services received outside the HMO or PPO network.
Out of Pocket Max (OOP) – After the patient has met their out-of-pocket maximum, they no longer have to pay anything (copay, coinsurance, or deductible). Typically, this happens towards the end of the year.
PHI – Protected Health Information (PHI) is any information that can be used to identify a person's health, treatment, or payment history. This includes information in medical records, as well as other information that can be used with the medical records to identify the patient. PHI is strictly governed by HIPAA.
An authorization, or precertification, is used by healthcare providers and the insurance company to ensure medical necessity of services. This is only required for certain procedures and varies by insurance company. The rendering provider or specialist will submit auth or precertification requests to the insurance company prior to the services being rendered. These requests include the patient’s demographic info, potential CPT codes for procedures to be rendered, diagnosis codes, and the service dates. Once approved, the insurance company will send the provider confirmation and an auth number to be submitted with the claim. Without this, services will not be paid for.
A referral is used when a patient is sent to another healthcare provider – usually by a primary care physician (PCP) referring to a specialist. Some insurance plans require an electronic referral number from the PCP before the specialist can see the patient. The specialist typically cannot obtain a referral without the PCP requesting it. Referrals may need to be updated occasionally, since some are only good for certain time frames or visits.
An ABN, or Advance Beneficiary Notice, is a waiver of liability that is signed by the Medicare patient prior to receiving certain services. By law, Medicare will only pay for services that are determined to be “reasonable and necessary.” Based on Medicare coverage guidelines, if it is unlikely the procedure will be paid for due to medical necessity, this must be completed prior to treatment. Payment is collected at time of service.
ROI – Release of Information (ROI) is a process that allows patients to share their medical records with authorized people or organizations. It's also the name of the document that authorizes the release of a patient's information
