GLOSSARY

TERM ABREVIATION DEFINITION

Patient PT Person that receives the treatment. Medical service
Patient Responsibility PR The portion of a medical bill that the patient is required to pay rather than their insurance provider
Co-Insurance COINS The amount you must pay after your insurance has paid its portion, according to your Benefit Contract. E.g: Ins 70% pt 30%
Co-Payment COPAY A predetermined, fixed fee that you pay at the time of service.
Deductible N/A The amount a patient pays before the insurance plan pays anything. In most cases, deductibles apply per person per calendar year.
Explanation of Benefits EOB A document attached to a processed claim that explains to the provider and patient what the insurance company provides, usually consisting of covered charges, payment methods, deductibles, patient responsibility and potential write-offs.
Electronic Remittance Advice ERA A digital version of an EOB; a document describing how much of a claim the insurance company will pay or why the claim was denied.
Date of Service DOS When a service took place.
Place of Service POS Where a service took place.
Coordination of Benefits COB This is which insurance agency is the primary provider versus the secondary provider when a patient has more than one policy.
Electronic Data Interchange EDI The electronic network that collects information before delving it out to particular individual insurance providers.
Electronic Funds Transfer EFT Transferring money electronically. A credit or debit charge or transfer must take place.
Out of Network OON A medical service provider that does not currently work with the specific insurance agency.
In-Network INN A medical care provider that is contracted with the specific insurance provider used by a patient.
Tax Identification Number TIN A nine-digit number that the IRS assigns to organizations for tax filing and tracking purposes.
Employer Identification Number EIN A type of TIN that the IRS assigns to organizations for tax filing and tracking purposes.
National Provider Identifier NPI A unique ten-digit identification number required by HIPAA for covered healthcare providers.
Workers’ Compensation/Workers' Comp WC A work-related injury insurance claim.
Appeal N/A A process by which you, your doctor or your hospital, can object to your health plan when you disagree with the health plan’s decision to deny payment for your care.
Prescription (Drugs) Rx Direction or order for the preparing and use of a medicine.
Diagnosis Dx The determination of the nature of a disease.
Centers for Medicare and Medicaid CMS The federal agency that runs the Medicare program. In addition, CMS works with the states to run the Medicaid programs.
CMS-1500/ HCFA-1500 N/A The standard form used by healthcare professionals and suppliers to bill insurance companies.
Current Procedural Terminology CPT A 5-digit numbering system that helps standardize professional and outpatient facility billing. There is a CPT code for certain types of medical services. Using this code allows healthcare providers and insurance companies to communicate and track billing more efficiently.
Health maintenance organization HMO These health insurance plans require enrolled patients to receive all their care from a specific group of providers . It may require your primary care doctor to make a referral before you can receive specialty care.
International Classification of Diseases, 10th edition ICD-10/ICD-10-CM A system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms and procedures recorded in conjunction with hospital care in the U.S.
Hospice N/A Provides care for patients with a prognosis of six months or less if their disease runs its natural course, as certified by a physician. Terminal illness.
Home Health Agency HHA Provides services that are brought to patients who require intermittent skilled nursing care, physical therapy, speech-language pathology services, or continued occupational services.
Medicare MCR Federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with end-stage renal disease (ESRD).
Medicare Beneficiary Identifiers MBI The 11-digits new identification number that has replaced SSN-based identifiers.
Medicare Part A N/A Covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
Medicare Part B N/A Helps pay for services from doctors and other health care providers, outpatient care, home health care, durable medical equipment, and some preventive services.
Medicare Part C/Medicare Advantage N/A A type of Medicare plan that uses private health insurance to cover all the services you'd receive under Medicare Parts A and B. It can be HMO or PPO.
Medicare Part D N/A The part of Medicare that covers most outpatient prescription drugs. Part D is offered through private companies either as a stand-alone plan, for those enrolled in Original Medicare, or as a set of benefits included with your Medicare Advantage Plan.
Preferred Provider Organization PPO A health plan that covers in and out-of-network providers, though in-network providers are generally cheaper for the patient. PCP referrals may not be required and most preventative care is covered at 100%.
Health Maintenance Organization HMO A healthcare policy that requires a gatekeeper or primary care physician. If a situation calls for further action, this gatekeeper will refer the patient to a different specialist.
Managed Care Organization MCO A health care company or a health plan that is focused on limiting costs, while keeping quality of care high. PPO, EPO, HMO and POS plans are considered MCOs.

Medicaid MCD Medicaid is a jointly funded federal and state health insurance plan administered by states for low income adults, pregnant women, children and people with certain disabilities.
Primary Care Physician PCP A doctor selected by the member to be the first physician contacted for any medical problem. The doctor acts as the member's regular physician and coordinates any other care the member needs, such as a visit to a specialist or hospitalization.
Medicare Secondary Payer MSP The term generally used when the Medicare program does not have primary payment responsibility - that is, when another entity has the responsibility for paying before Medicare. Most common case: Individual is age 65 or older, is covered through current employment or spouse’s current employment.