Most Commonly Used Medical Billing Terms
Adjudication – Processing and settlement of claim by the insurance payer per their payment rules and guidelines.
Appeal – Process of objecting to insurance payer decision to deny payment.
Assignment of Benefits (AOB) – Insurance payments to healthcare provider for patient treatment.
Beneficiary – Person covered by the health insurance plan receiving the benefit.
Clearinghouse – Service that transmits a batch of claims to individual insurance carriers after checking for errors.
CoPay – Amount paid by patient at each visit.
CoInsurance – Percentage or amount defined in the insurance plan for which the patient is responsible.
Coordination of Benefits – Coordination of insurance coverage when a patient is covered by more than one insurance plan.
Credentialing – application process for a provider to participate with an insurance carrier.
Crossover Claim – When claim information is automatically sent from primary to secondary insurance.
CMS-1500 – Medical claim form established by CMS to submit claims to insurance payers.
Day Sheet – Daily summary of patient treatments, charges, and payments.
Deductible – Amount patient must pay before insurance coverage begins.
Fee Schedule – Cost associated with each treatment CPT medical billing codes
Guarantor – A responsible party and/or insured party who is not a patient
Inpatient – Hospital stay more than 24 hours
Insured – Person through which the health insurance policy is issued
Modifier – Modifier to a CPT treatment code that provide additional information
Medical Necessity – Service or procedure that is performed on for treatment of an illness or injury and determined to be necessary.
Medicare – Insurance provided by federal government for people over 65 or people those with certain restrictions.
Medicaid – Insurance coverage for low income patients.
Payer – Health insurance payer
Practice Management Software also called Medical Billing Software is used to create electronic claims and manage patient accounts.
Provider – Physician or medical care facility who provides health care services.
Privacy Rule – HIPAA privacy standard
Security Standard – HIPAA policy to safeguard PHI
Superbill – Customized form the provider uses to document treatment and diagnosis for a patient visit.
TRICARE – Federal health insurance for active duty military and their families.
Medical Billing Acronyms & Abbreviations
AMA – American Medical Association
BCBS – Blue Cross Blue Shield
CMS – Centers for Medicare and Medicaid Services
CPT- Current Procedural Terminology. The 5 digit code assigned a procedure performed by the physician
DME – Durable Medical Equipment
DOS – Date of Service
Dx – Abbreviation for diagnosis code
EMR – Electronic Medical Records
EOB – Explanation of Benefits
ERA – Electronic Remittance Advice
E/M – Evaluation and Management section of the CPT codes
HCPCS – Health Care Financing Administration Common Procedure Coding System (pronounced “hick-picks”)
HIPAA – Health Insurance Portability and Accountability Act
ICD – International Classification of Diseases
NOS – Not Otherwise Specified
NPI – National Provider Identifier
PHI – Protected Health Information
POS – Place of Service
RVU – Relative Value Units
SOF – Signature on File