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Advance Beneficiary Notice (ABN)

Document used to notify a Medicare beneficiary that it is either unlikely that Medicare will pay or certain that Medicare will not pay for the service they are going to be provided.

Outstanding Check

A check that has been written and recorded in the checkbook but has not yet cleared the bank.

Explanation of Benefits (EOB)

Printed description of the benefits provided by the insurer to the beneficiary; provides information about how an insurance claim was paid.

Coinsurance

Percentage that a patient is responsible for paying for each service after the deductible has been met.

Exclusive Provider Organization (EPO)

An EPO requires patients to use their EPO’s provider network for care, with no partial coverage for out-of-network care.

Health Maintenance Organization (HMO)

A type of managed care organization typically set up as a for-profit corporation with salaried employees; entitles members to services from participating providers.

Preauthorization

Prior approval of insurance coverage and the necessity of a procedure before the patient receives the services.

Third Party Liability (TPL)

Legal obligation of third parties to pay for some or all expenditures for medical assistance under a state plan.

Third Party Reimbursement

Payment for services rendered by someone other than the patient, usually involving health care providers submitting claims to the source of payment.

Subscriber

The person who has been insured; the insurance policyholder.

Medicaid

Joint funding program by federal and state governments for the medical care of low-income patients on public assistance.

Medicare

Federal program providing health care coverage for individuals over the age of 65 or those who are disabled.

Indemnity-Type Insurance

Type of insurance plan with the least structural guidelines for patients, allowing them to choose any provider.

Preferred Provider Organization (PPO)

Organization of physicians who network together to offer discounts to health care insurance purchasers.

Comorbidity

Condition that exists alongside the primary diagnosis of a patient.

Current Procedural Terminology (CPT)

Numerical listing of procedures performed in medical practice; standardized identification of procedures.

HCPCS Level II Codes

Alphanumeric codes identifying products, supplies, and services not included in CPT codes, maintained by CMS.

Reconciling

Process to bring checkbook and bank statement into agreement.

National Provider Identifier (NPI)

Standard unique health identifier for health care providers.

Secondary Insurance

Exists when a patient has more than one insurance plan, with charges first submitted to the primary carrier.

Crossover Claim

Insurance claim automatically transferred from Medicare to a secondary payer after Medicare processes it.

Clearinghouse

Acts as an intermediary in medical billing to ensure clean and accurate claim submissions to insurance companies.

Centers for Medicare and Medicaid Services (CMS)

Federal agency responsible for administration of Medicare and Medicaid.

Stop Payment

Method by which the maker of a check can stop payment of a written check.

International Classification of Diseases (ICD)

Comprehensive listing of diseases and disorders, with ICD-10-CM codes describing the patient’s condition.