Glossary of Billing Terms S thru Z

S thru Z Glossary of billing terms with short definitions commonly used in the field of medical billing and coding.

A – E F – K L – R

Scrubbing – Process of checking an insurance claim for errors in the health insurance claim software prior to submitting to the payer.

Self-Referral – When a patient sees a specialist without a primary physician referral.

Self Pay – Payment made at the time of service by the patient.

Secondary Insurance Claim – claim for insurance coverage paid after the primary insurance makes payment. Secondary insurance is typically used to cover gaps in insurance coverage.

Secondary Procedure – When a second CPT procedure is performed during the same physician visit as the primary procedure.

Security Standard – Provides guidance for developing and implementing policies and procedures to guard and mitigate compromises to security. The HIPAA security standard is kind of a sub-set or compliment to the HIPAA privacy standard. Where the HIPAA policy privacy requirements apply to all patient Protected Health Information (PHI), HIPAA policy security laws apply more specifically to electronic PHI.

Skilled Nursing Facility – A nursing home or facility for convalescence. Provides a high level of specialized care for long-term or acutely ill patients. A Skilled Nursing Facility is an alternative to an extended hospital stay or home nursing care.

SOF – Signature on File.

Software As A Service (SAAS) – One of the medical billing terms for a software application that is hosted on a server and accessible over the Internet. SAAS relieves the user of software maintenance and support and the need to install and run an application on an individual local PC or server. Many medical billing applications are available as SAAS.

Specialist – Pphysician who specializes in a specific area of medicine, such as urology, cardiology, orthopedics, oncology, etc. Some heathcare plans require beneficiaries to obtain a referral from their primary care doctor before making an appointment to see a Specialist.

Glossary of Billing Terms

Subscriber – Medical billing term to describe the employee for group policies. For individual policies the subscriber describes the policyholder.

Superbill – One of the medical billing terms for the form the provider uses to document the treatment and diagnosis for a patient visit. Typically includes several commonly used ICD-9 diagnosis and CPT procedural codes. One of the most frequently used medical billing terms.

Supplemental Insurance – Additional insurance policy that covers claims fro deductibles and coinsurance. Frequently used to cover these expenses not covered by Medicare.

TAR – Treatment Authorization Request. An authorization number given by insurance companies prior to treatment in order to receive payment for services rendered.

Taxonomy Code – Specialty standard codes used to indicate a providers specialty sometimes required to process a claim.

Term Date – Date the insurance contract expired or the date a subscriber or dependent ceases to be eligible.

Tertiary Insurance Claim – Claim for insurance coverage paid in addition to primary and secondary insurance. Tertiary insurance covers gaps in coverage the primary and secondary insurance may not cover.

Third Party Administrator (TPA) – An independent corporate entity or person (third party) who administers group benefits, claims and administration for a self-insured company or group.

TIN – Tax Identification Number. Also known as Employer Identification Number (EIN).

TOP – Triple Option Plan. An insurance plan which offers the enrolled a choice of a more traditional plan, an HMO, or a PPO. This is also commonly referred to as a cafeteria plan.

TOS – Type of Service. Description of the category of service performed.

TRICARE – This is federal health insurance for active duty military, National Guard and Reserve, retirees, their families, and survivors. Formerly know as CHAMPUS.

UB04 – Claim form for hospitals, clinics, or any provider billing for facility fees similar to CMS 1500. Replaces the UB92 form.

Glossary of Billing Terms

Unbundling – Submitting several CPT treatment codes when only one code is necessary.

Untimely Submission – Medical claim submitted after the time frame allowed by the insurance payer. Claims submitted after this date are denied.

Upcoding – An illegal practice of assigning an ICD-9 diagnosis code that does not agree with the patient records for the purpose of increasing the reimbursement from the insurance payor.

UPIN – Unique Physician Identification Number. 6 digit physician identification number created by CMS. Discontinued in 2007 and replaced by NPI number.

Usual Customary & Reasonable(UCR) – The allowable coverage limits (fee schedule) determined by the patients insurance company to limit the maximum amount they will pay for a given service or item as defined in the contract with the patient.

Utilization Limit – The limits that Medicare sets on how many times certain services can be provided within a year. The patients claim can be denied if the services exceed this limit.

Utilization Review (UR) – Review or audit conducted to reduce unnecessary inpatient or outpatient medical services or procedures.

V-Codes – ICD-9-CM coding classification to identify health care for reasons other than injury or illness.

Workers Comp – Insurance claim that results from a work related injury or illness.

Write-off – Typically reference to the difference between what the physician charges and what the insurance plan contractually allows and the patient is not responsible for. May also be referred to as “not covered” in some glossary of billing terms.

Glossary of Billing Terms S thru Z

A – E F – K L – R