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Glossary of Billing Terms
Beneficiary / Insured - someone who is eligible to receive benefits under an insurance policy or plan.
Beneficiary / Insured Liability - the amount beneficiaries
must pay for covered services. These include co-payments,
coinsurance, deductibles and balance billing amounts.
Co-insurance - a type of cost sharing where the beneficiary
/ insured and insurance provider share payment of the approved
charge for covered services in a specified ratio after payment of
the deductible by the insured. For example, for Medicare
physicians' services, the beneficiary pays co-insurance of 20
percent of allowed charges.
Coordination of Benefits (COB) - a provision in healthcare
that determines the insurances’ and patient’s share of the
expenses.
Co-payment – (1) A fixed dollar amount paid for a covered
service by a beneficiary / insured (See Co-insurance and
Deductible). (2) Amount that a member of a health plan has to pay
for specific health services, such as visits to a physician. (See
"Beneficiary Liability" and Co-insurance”)
Date Of Service (DOS) – the date(s) healthcare services
were provided
Deductible – The amount of eligible expense a beneficiary /
insured person must pay each year out of pocket before the plan
will make payment for eligible benefits.
Explanation of Benefits (EOB) – the insurance company’s
statement that lists services rendered, amount billed and payment
made. This normally would include any amounts due from the patient
such as "Beneficiary Liability," "Co-insurance," "Deductible" and
or "Co-payment" amount.
Health Insurance – coverage that provides for the payment
of benefits as a result of sickness or injury. Includes insurance
for losses from accident, medical expense, disability, or
accidental death and dismemberment.
Health Maintenance Organization (HMO) - an entity that
provides, offers or arranges for coverage of designated health
services needed by plan members for a fixed, prepaid premium.
Medicaid / AHCCCS – A state/federal benefit program for the
poor who are aged, blind, disabled or members of families with
dependent children. Each state sets its own eligibility standards.
Only 40 percent of individuals with income below the poverty level
currently are covered.
Medicare – A federal health benefit program for people over
65 and disabled that covers 35 million Americans.
Out of Network (OON) – coverage for services obtained from
a non-participating provider. Typically, it requires payment of a
deductible and higher co-payments and co-insurance than for
treatment from a participating provider.
Part A Medicare – Medicare Part A (Hospital Insurance)
helps cover your inpatient care in hospitals, critical access
hospitals, and skilled nursing facilities (not custodial or
long-term care). It also helps cover hospice care and some home
health care. You must meet certain conditions.
Part B Medicare – Medicare Part B (Medical Insurance) helps
cover your doctors’ services and outpatient hospital care. It also
covers some other medical services that Part A doesn’t cover, such
as some of the services of physical and occupational therapists,
and some home health care. Part B helps pay for these covered
services and supplies when they are medically necessary.
Primary Care Physician (PCP) – a physician, the majority of
whose practice usually is devoted to internal medicine,
family/general practice and pediatrics. An
obstetrician/gynecologist sometimes is considered a primary care
physician, depending on coverage.
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