Introduction to Insurance Billing Terminology

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audit

to check the accuracy of financial accounts and records

Explanation of Benefits (EOB)

document sent by the insurance company to the provider and the patient explaining the allowed charge amount, the amount reimbursed for services, and the patient's financial responsibilities.

EOB

explanation of benefits

Copayment

a fixed fee paid by the patient at the time of an office visit

Deductible

a specified amount of money that the insured must pay before an insurance company will pay a claim

indigent

(adj.) needy, impoverished

beneficiary

A designated person who receives funds from an insurance policy.

claim

A formal request for payment from an insurance company for service provided.

fee schedule

A list of the fixed fees for services is a

capitation

A payment arrangement for healthcare providers in which the provider is paid a set amount whether the patient received services or not.

Co-insurance

A percentage of the bill that patient must pay after meeting the deductible.

Precertification

A process required by some insurance carriers in which the provider must prove medical necessity before performing a procedure.

RBRVS

A system used to determine how much providers should be paid for service rendered.

policy

A written agreement between two parties, in which one party agrees to pay another party if certain specified circumstances occur.

provider network

An approved list of physicians, hospitals and other providers

health insurance exchange

An online marketplace where you can compare and buy individual health insurance plans.

online insurance web portal

An online service which allows providers to look up patient's insurance information.

referral

An order from a primary care provider for the patient to see a specialist or obtain services.

Claims Clearinghouse

An organization that accepts claims from the provider and reformats the data and submits the claim.

eligibility

Meeting the requirements to participate in the healthcare plan.

medical necessity

Services or supplies that are used to treat the patient's diagnosis meet the accepted standard of medical practice.

Medically necessary

Services that are needed to improve the patient's current health are considered

NPI

The identifier assigned to healthcare providers by license and medical specialties.

gatekeeper

The primary care provider who is in charge of a patient's treatment

adjudicate

To settle or determine with a court of law.


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