Help and Frequently Used Terms

Still Have Questions?

Screencast How-Tos

Adjusted Gross Income is an income figure computed when calculating taxes. It is based on gross income, less any business expenses and deductions like retirement account contributions or alimony. Itemized deductions, such as medical expenses, interest payments, and real estate taxes, are included in the adjusted gross income calculation and not subtracted out until "net taxable income" is determined.

Adjustment (see Network Discount)

Allied Practitioner is a professionally degreed healthcare service provider other than a Physician M.D.

Allowed Amount is the amount of payment a provider has agreed to accept for a service, treatment or product under the terms of a negotiated contract with an insurer (also Adjusted Amount, Allowed Bill, Allowed Rate, Negotiated Rate)

Amount Applied to Deductible is the amount of a patient responsibility which is credited against the deductible in a healthcare plan.

Balance is the amount remaining from a debt once all existing payments and adjustments have been considered.

Bill is the paperwork received from a provider which documents the services rendered and shows the gross amount billed for those services. This amount should match the claim amount submitted to the insurer. See also super bill.

Billed Amount is the amount initially billed by a provider for a service, treatment or product.

Billing Date is the date on which a bill was issued.

CDHP (see Consumer Directed Healthcare Plan)

CPT (see Current Procedural Codes)

Capitated Contract refers to a contract between an insurer and a provider under which the provider agrees to accept set amounts for products and services rendered to those people under the insurers policy.

Caregiver is a person responsible for the well-being of a patient. Generally a family member or close companion.

Claim is an instance of a bill submitted to an insurer in anticipation of receiving payment for services rendered for covered services.

Claim Number is a number assigned to a claim by an insurer.

Clinic is a licensed facility where healthcare services are rendered to patients.

Co-Pay (also Co-Payment) is the amount that a patient is expected to pay at the time of service.

Co-Insurance is the ratio of your coverage after the deductible has been met.

Co-Payment (see Co-Pay)

Collections Notice is a notice received that demands payment of overdue debt for a bill(s).

Consumer Directed Healthcare Plan (or CDHP) is a healthcare plan in which the consumer directs and is responsible for payment up to the generally higher deductible amount and the insurer accepts payment responsibility only after that obligation has been reached by the consumer.

Coverage is the defined scope of services provided under a healthcare policy.

Current Procedural Codes more commonly know as CPT are the codes used by physicians to communicate a medical, surgical or diagnostic service primarily for the purpose of submitting a claim for reimbursement of the service.

DRG (see Diagnosis Related Groups)

Denial of Coverage is the refusal of an insurer to accept responsibility as the guaranteed payor for services, treatments or products considered outside the scope of a defined healthcare plan.

Dental refers to preventative healthcare related to the teeth.

Diagnosis Related Groups more commonly known as DRG is a code used by hospitals to classify cases primarily for the purpose of prospective reimbursement.

Disease Management is the proactive management of health issues in an effort to reduce healthcare costs.

Donut Hole is the phase of a Medicare enrollee's pharmaceutical plan under the Medicare Part D prescription drug program that costs are not covered by Medicare.

EOB (see Explanation of Benefits)

ERISA (see Employee Retirement Income Security Act)

Employee Retirement Income Security Act is a federal law enacted in 1974 that places responsibility for the oversight of insurers at the state level unless a company is self-insured in which case responsibility falls under the federal government.

Explanation of Benefits or EOB is a documentation of a claim and the allocation of financial responsibility for that claim. An EOB is specific to a provider and the service(s) rendered by that provider. The format varies widely between insurers, but at a minimum should indicate the Provider, Service Date, Actual Billed Amount, Network Discount, Allowed Amount, Insurance Portion, Patient Responsibility, Deductible Amount.

FSA (see Flexible Spending Account)

Filed By is either a provider or a patient. This option is used to designate if the provider submits the claim to the insurer or if the patient submits the claim to the insurer.

Flexible Spending Account (or FSA) is generally an employer-funded account that receives pre-tax dollars and can be used for a multitude of personally related expenses that are tax-deductible included childcare and healthcare.

Family Member is for the purpose of an insurer a spouse or child (natural, adopted or otherwise legally bound) under a specified age depending on insurer requirements in compliance with state and federal laws.

Gatekeeper is a primary care physician through whom a patient receives a referral to a specialist.

Guaranteed Payor is an entity which under contract pledges payment for services, treatments or product.

HDHP (see High Deductible Healthcare Plan)

HIPAA (see Healthcare Information Portability and Accountability Act)

HMO (see Healthcare Maintenance/Management Organization)

HRA (see Healthcare Retirement Account)

HSA (see Healthcare Savings Account)

Healthcare Information Portability and Accountability Act is federal legislation regarding patient's rights with respect to the handling and privacy of an individual's healthcare records by healthcare industry professionals.

Healthcare Maintenance/Management Organization is a type of Managed Care Organization (MCO) that provides a form of health insurance coverage that is fulfilled through hospitals, doctors, and other providers with which the HMO has a contract

Healthcare Saving Account (aka Healthcare Spending Account) is the savings account associated with a HDHP from which the consumer pays their deductible.

Healthcare Spending Account (see Healthcare Saving Account)

High Deductible Healthcare Plan is (HDHP or CDHP) is a health insurance plan with lower premiums and higher deductibles than a traditional health plan. It is sometimes referred to as a consumer directed health plan. Participating in a "qualified" HDHP is a requirement for Health Savings Accounts and other tax advantaged programs. Hospital is

ICD (see International Classification of Diseases)

Income Tax is federal tax on earnings and wages.

Insurer is a guaranteed payor authorized on a state by state basis as a result of ERISA. Insurers are able to provide coverage only within their home state. Insurers may also be referred to as guaranteed payors because they have contracts with providers which guarantee the provider payment for services rendered.

International Classification of Diseases more commonly know as ICD is an international standard for communicating information regarding disease among all countries.

Lab is an outside medical services provider which performs tests.

Medical Tax Deduction is an itemized schedule eligible for tax writeoff.

Medicare is an insurance program that is jointly funded by the states and the federal government but is administered by each State to provide health care for certain poor and low-income individuals and families in order to reimburse hospitals and physicians for providing care to qualifying people who cannot finance their own medical expenses. Eligibility and other features vary from State to State but Medicaid benefits generally cover basic health care and long-term care services for eligible persons. States that choose to participate in Medicaid must offer the following basic services:

• hospital care, both inpatient and outpatient
• nursing home care
• physician services
• laboratory and diagnostic x ray services
• immunizations and other screening, diagnostic, and treatment services for children
• family planning, health center and rural health clinic services
• nurse midwife, nurse practitioner, and physician assistant services

Participating states may also offer the following optional services and receive federal matching funds for them:

• prescription medications
• institutional care for the mentally retarded
• home- or community-based care for the elderly, including case management
• personal care for the disabled
• dental and vision care for eligible adults

Medicare HMO (aka Part C) permits Medicare recipients to select coverage among various private health care plans to include HMOs, PPOs, Point-Of-Service (POS), Medical Savings Accounts (MSAs), fee-for-service plans, and provider-sponsored plans. These plans will receive a per capita payment per enrollee from the federal government, and the plans have the option to charge the enrollees a monthly premium. Persons who are eligible for Medicare Part A and are enrolled in Medicare Part B are eligible for enrollment in either the traditional Medicare program or this new Medicare HMO (Part C) program. Each November, the health care financing administration will conduct open enrollment periods so that persons may select the type of health care program in which they wish to participate.

Medicare Part D prescription drug program (or Medciare Part D) is (see also Donut Hole) is a federal government program to subsidize the costs of prescription drugs for Medicare beneficiaries in the United States. The benefit is administered by private insurance plans that are reimbursed by the Centers for Medicare and Medicaid Services (CMS). Beneficiaries can obtain the Medicare Drug benefit through two types of private plans: beneficiaries can join a Prescription Drug Plan (PDP) for drug coverage only or they can join a Medicare Advantage plan (MA) that covers both medical services and prescription drugs (MA-PD). Those who enroll in the Medicare Part D program choose from a large list of approved drug plans which do not cover all prescription drugs, so it is important that they choose a plan that meets their needs.

Medicare Supplemental (aka Medigap Insurance) is an insurance policy designed to act as a supplement to Medicare. Medicare Supplemental insurance is intended to complement not replace Medicare as a primary means of coverage. The supplementation is in the form of additional benefits to that provided by Medicare and are in the form of payment for medical expenses incurred but excluded by Medicare's deductibles, by limitations on approval medical charges, by limitations on length and type of care in nursing facilities, and by limitations imposed by various cost-sharing requirements. Most of these policies pay substantially less than 100% of the expenses not covered under Medicare. Insurance companies that sell Medigap policies are required by law to have an open enrollment period of six months for those individuals who first enroll in Medicare Part B at age 65 or older. Insurance companies can, however, exclude preexisting conditions from the data of initial coverage, but for no more than six months. Each policy is mandated to provide a basic amount of benefits.

Medicaid is a state and federally funded form of insurance for medically handicapped and/or chronically ill Americans.

Mileage is the distance traveled in a personal vehicle for the purpose of receiving healthcare treatment or services.

NDC (see National Drug Code)

Named Insured is the person through whom a policy is secured. For an employer-sponsored plan, that named insured would be the employee.

National Drug Code is an identifying code unique to each drug and its dosage. It has a standardized XXXX-XXXX-XX format.

Network Discount is the amount by which a provider's bill is adjusted as a result of a negotiated rate covered under a negotiated capitated contract between the provider and the insurer. The network discount term often appears on an Explanation of Benefits, but it does not appear on all since those forms vary by insurer. Insurers use many variations on this term including Adjustment, etc.

Out of Network refers to providers who are not directly contracted with an individual's insurer to provide services at a pre-determined rate. Most insurers maintain a capitated contract with the providers commonly used by their insured. Many of these contracts are regionally confined since insurers are authorized on a state by state basis as a result of ERISA.

Negotiated Rate/Amount (see Allowed Amount)

OTC (see Over the Counter)

Out-of Pocket is an amount personally paid by the insured patient for healthcare expenses.

Over the Counter (or OTC) is any drug requiring a prescription for purchase.

PCP (see Primary Care Physician)

PPO (see Preferred Provider Organization)

POS (see Point of Service)

Patient is the individual receiving care.

Patient Advocate is a person who speaks for the patient in instances where the patient is unable to communicate effectively for themselves or when the patient lacks the subject matter knowledge to communicate effectively.

Payment Method is the means by which a payment was made (i.e. cash, check, credit card, etc.)

Payor is the entity (company or individual) making payment on an outstanding debt.

Pharmacy is a retail-based establishment where pharmaceutical prescriptions and other medications are dispensed.

Physician is any type of medical doctor.

Policy is a contract between an insured and an insurer detailing what services are covered by the insurer.

Policy Holder is a person covered under an insurance policy

Practitioner is anyone licensed to provide healthcare services.

Pre-Authorization is the confirmation of coverage for a service or product by the insurer prior to the rendering of the service or disbursement of the product.

Premium is the amount paid for an insurance coverage.

Preferred Provider Organization (or PPO) is a managed care organization of medical doctors, hospitals, and other health care providers who have contracted with an insurer or a third-party administrator to provide health care at reduced rates to the insurer's or administrator's clients.

Prescription is a physician-approved authorization for a medication.

Primary Care Physician (or PCP) is a physician selected within an HMO plan as the person who will act as the point of reference through which all referrals other than emergency must go.

Primary Insurance is the first insurer when more than one insurance policy provides coverage. The primary insurance often sets the allowed amount that a provider is able to bill. There is a coordination of benefits which must take place when there is more than one insurance in effect. Benefits from a primary insuror must be completed before submitting a claim to a secondary insuror.

Private Insurance is insurance provided through an entity either for profit or not for profit and other than the federal or state government.

Providers are anyone who provides medically related services that can be reimbursed. A provider may be a physician, dentist, clinic, hospital, pharmacy, lab, physical therapists or other allied practitioners.

Provider Accepts Adjustment is a term referring to the fact that a provider has agreed to a negotiated rate with an insurer.

RBC (see Retail Based Clinic)

Reason for Visit is the condition(s) or symptom(s) that prompted a provider contact resulting in a bill. The Reason for Visit is a plain language means for the layperson to input a condition. See also CPT code.

Referral is a recommendation by a gatekeeper to a specialist or from one specialist to another specialist.

Reimbursement is payment made for services rendered. Reimbursement may be made to a provider or to a patient in the event that overpayment has been made or the patient pre-paid and submitted for reimbursement directly from their insurer.

Retail Based Clinic (or RBC) are non-acute care providers based in retail establishments such as pharmacies, department stores and grocery stores for the purpose of convenience.

Sandwich Generation is someone who has the responsibility for care of both their own children and their elderly parents.

Secondary Insurance is an insurance which provides coverage in addition to that of a primary insurance. Secondary insurance generally covers services not covered or not completely covered by the primary insurance. When a person has a secondary insurance or even a tertiary insurance, there must be coordination of benefits.

Self Pay is payment for service by the patient at the time services are rendered.

Service Date is the date on which a service was rendered by a provider.

Specialty is a provider's specific area of expertise.

Specialist is a medical professional with concentrated expertise in a specific field of medicine (i.e. oncology, podiatry, etc.). (See also specialty)

Statement is a summary of all outstanding activity on an open account balance.

Super Bill is a term implying a more extensive line item documentation of a bill from a provider.

Tags are keywords that are used to group records.

Tax Deductible is a term referring to expenses which are excluded from federal income tax.

Tertiary Insurance is the third insuror when more than one insurance is in effect. See also primary insurance, secondary insurance and coordination of benefits.

Transaction Log is a sortable list of all activity within an account.

Tricare is the United States military managed health care program for the military, dependents and retirees and replaced the previous CHAMPUS plan. The program is managed by TRICARE Management Activity (TMA) and contracts with several large health insurance corporations to provide claims processing, customer service and other administrative functions. Currently, there are three regional Managed Care Support Contractors, a Medicare/TRICARE Dual Eligible Fiscal Intermediary Contractor and a TRICARE Pharmacy contractor, who administers both Mail Order Pharmacy and Retail Pharmacy programs. TMA also oversees the TRICARE Dental Program and TRICARE Retiree Dental Program. There are three different TRICARE plans:

TRICARE Standard provides a similar benefit to the original CHAMPUS program. Beneficiaries can use any civilian health care provider that is payable under TRICARE regulations. The beneficiary is responsible for payment of an annual deductible and coinsurance, and may be responsible for certain other out-of-pocket expenses. There is no enrollment in TRICARE Standard.

TRICARE Extra allows Standard beneficiaries to elect to use a civilian health care provider from within the regional contractor's provider network. TRICARE Extra represents a preferred provider organization (PPO) and the beneficiary's coinsurance amount is reduced by at least five percentage points. There is no fee for use of the TRICARE Extra benefit other than the coinsurance.

TRICARE Prime is a health maintenance organization (HMO) style plan. Beneficiaries must choose a primary care physician and obtain referrals and authorizations for specialty care. In return for these restrictions, beneficiaries are responsible only for small copayments for each visit. There is an annual enrollment fee for TRICARE Prime for military retirees and their family members. There is no enrollment fee for active duty military and their family members.

Underinsured refers to instances where financial strain may result from inadequate coverage to address the financial expenses associated with healthcare services.

Uninsured is someone without healthcare coverage.

Vision refers to portions of a policy which cover basic eye care including regular checkups and an regular stipend for corrective lenses or contacts.

Will Bill is a designation that notes whether a patient expects to receive a bill for services. There may be situations where the payment serves as the bill (i.e. a pharmacy purchase).

Worker's Comp or Worker's Compensation provides insurance to cover medical care and compensation for employees who are injured in the course of employment, in exchange for mandatory relinquishment of the employee's right to sue their employer for the tort of negligence. While plans differ between jurisdictions, provision can be made for weekly payments in place of wages (functioning in this case as a form of disability insurance), compensation for economic loss (past and future), reimbursement or payment of medical and like expenses (functioning in this case as a form of health insurance), and benefits payable to the dependents of workers killed during employment (functioning in this case as a form of life insurance). The benefits are administered on a state level, primarily by the state department of labor.