AHM/CCMA Week 10 Billing and Coding Terms

Authorization

When a patient's health insurance plan requires them to get permission from their insurance providers before receiving certain healthcare services. A patient may be denied coverage if they see a provider for a service that needed authorization without first consulting the insurance company.

Beneficiary

Person who receives benefits and/or coverage under a healthcare plan may not be the person paying for the plan, as is the case for young children covered under their parents' plans.

CMS-1500

paper medical claim form used for transmitting claims based on coverage by Medicare and Medicaid, and often by commercial insurance providers.

Co-Insurance

The percentage of coverage that a patient is responsible for paying after an insurance company pays the portion agreed upon in a health plan.

Co-Pay

The amount that must be paid to a provider before they receive any treatment or services, separate from a deductible, and will vary depending on a person's insurance plan.

Birthday Rule

A rule to determine coordination for benefits for a child covered by both parents; it dictates that the parent with the first birthday in the calendar year will provide the primary coverage; if both parents happen to have the same birthday, the plan that has covered a parent longer pays first.

Current Procedural Technology (CPT) Code

Codes that represent treatment and procedures performed by a physician in a 5 digit format, used with ICD-10 codes that explain a patient's diagnosis.

Deductible

The amount a patient must pay before an insurance carrier starts their healthcare coverage.

Dx

Abbreviation for diagnosis codes, or ICD-10 codes.

Explanation of Benefits

A document attached to a processed medical claim wherein the insurance company explains the services they will

cover for a patient's healthcare treatments. It may also explain what is wrong with a claim if it's denied.

Group Name/Number

Name or number that identifies the group or plan in which an individual is covered.

ICD-10 Codes

International set of codes that represent diagnoses of medical conditions, used for insurance processing. Formerly known as ICD-9 codes.

In-network

This term refers to a provider's relationship with a health insurance company. A group of providers may contract with an insurance company to form a network of healthcare professionals that a person can choose from when enrolled in that insurance company's health plan.

Medical Necessity

This term refers to healthcare services or treatments that a patient requires to treat a serious medical condition or illness. This does not include cosmetic or investigative services.

Not otherwise specified (NOS)

This term is used in ICD-10 codes to describe conditions with unspecified diagnoses.

Out of Network

Providers outside of an established network of providers who contract with an insurance company to offer patients healthcare at a discounted rate. People who go to these types of providers typically have to pay more money to receive care.

Premium

The sum a person pays to an insurance company on a regular (usually monthly or yearly) basis to receive health insurance.

Subscriber

The individual covered under a group policy.

Superbill

A document used by healthcare staff and physicians to write down information about a patient receiving care. It can contain demographic information, insurance information, and especially any diagnoses or healthcare plans written by the physician. Also known as an encounter form.

Write-off

The discrepancy between a provider's fee for healthcare services and the amount that an insurance company is willing to pay for those services that a patient is not responsible for. May be categorized as "not covered" amounts for billing purposes.