Medical Billing Jargon

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.

This page has a more complete listing of Medical Billing Terms.

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

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