What is TOS and POS and its meaning

by Anitha

I hope this answers your question Anitha:

POS is an abbreviation for Place of Service and is used on medical insurance claims – such as the CMS 1500 block 24B. This is a 2 digit code which defines where the procedure was performed. For example 11 is for the doctors office, 12 is for home, 21 is for inpatient hospital, etc.

TOS is an abbreviation for Type of Service indicator. This used to be used on the old CMS-1500 (dated 12-90) forms in box 24C. It’s no longer use on the new CMS-1500 forms. Here’s a link that describes the TOS Indicators (scroll to bottom of page).

Here’s a good Step-by-Step Guide for filling out the CMS 1500 Form.

If used as abbreviations with regard to Managed Health Care terminology:

POS is Point-of-Service plan. This is a flexible type of HMO (Health Maintenance Organization) plan where patients have the freedom to use (or self-refer to) non-HMO network providers. When a non-HMO specialist is seen without referral from the Primary Care Physician (self-referral), they have to pay a higher deductible and a percentage of the coinsurance (typically 20 to 30%).

When the patient gets authorization from the Primary Care Physician for specialty treatment outside the HMO, they only pay the regular copayments and no deductible or coinsurance payments are required.

With regard to TOS – did you mean TOP?

TOP stands for Triple Option Plan. This is 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.

Triple Option Plans can be an advantage when covering those who tend to suffer from more frequent illness. It allows a larger group of people to minimize risk and cost.

Hope this answers your question.


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