Lesson 2: Medical Billing & Coding Terminology & Acronyms
Subscriber: The employee for group policies. For individual policies the subscriber describes the policyholder.
Superbill: The form the provider uses to document the treatment and diagnosis for a patient visit.
Supplemental Insurance: Additional insurance policy that covers claims for deductibles and coinsurance.
Place of Service: A two digit code on medical claims which defines where the procedure was performed.
PPO (Preferred Provider Organization): Commercial insurance plan where the patient can use any doctor or hospital within the network.
Practice Management Software: Software used for the daily operations of a provider’s office, typically for appointment scheduling and billing.
Preauthorization: Requirement of insurance plan for primary care doctor to notify the patient insurance carrier of certain medical procedures.
Pre-Certification: Sometimes required by the insurance company to determine medical necessity for services proposed or rendered.
Predetermination: Maximum payment insurance will pay towards surgery, consultation, or other medical care – determined before treatment.
Pre-existing Condition (PEC): A medical condition that has been diagnosed or treated within a specified period before the patient’s effective date of coverage.
Premium: The amount the insured or their employer pays (usually monthly) to the health insurance company for coverage.
Privacy Rule: The HIPAA privacy standard that establishes requirements for disclosing Protected Health Information (PHI).
Protected Health Information (PHI): An individual’s identifying information such as name, address, birth date, Social Security Number, or information pertaining to healthcare diagnosis or treatment.
Provider: Physician or medical care facility (hospital) who provides health care services.
PTAN: Provider Transaction Access Number. Also known as the legacy Medicare number.
HIPAA (Health Insurance Portability and Accountability Act): Federal regulations intended to improve efficiency and effectiveness of health care and establish privacy and security laws for medical records.
HMO (Health Maintenance Organization): A type of health care plan that places restrictions on treatments.
Hospice: Inpatient, outpatient, or home healthcare for terminally ill patients.
Coordination of Benefits (COB): When a patient is covered by more than one insurance plan. One insurance carrier is designated as the primary carrier and the other as secondary.
Co-Pay: Amount paid by patient at each visit as defined by the insured plan.
CPT Code (Current Procedural Terminology): A 5 digit code assigned for reporting a procedure performed by the physician. Established by the American Medical Association.
Credentialing: An application process for a provider to participate with an insurance carrier. Many carriers now request credentialing through CAQH.
Credit Balance: The balance shown with a minus sign or in parentheses indicating the provider may owe the patient a refund.
Crossover Claim: When claim information is automatically sent from Medicare to the secondary insurance such as Medicaid.