Here is our Medical Billing Glossary for definition of medical billing terms to help you understand your statement and the entire medical billing process.
Account Number: Your account number with your health care provider.
Accounts Receivable: An amount due from you or your insurance organization for services a physician group or facility provided.
Adjustments: Transactions that increase or decrease your accounts receivable balance. Debits increase your balance. Credits decrease your balance.
Amount: How much was paid or adjusted – or how much that’s owed for this service.
Assignment of Benefits: An agreement in which you instruct your insurance organization to pay the hospital, physician or medical supplier directly for your medical services. Your insurance organization decides the payment rate.
Bad Debt: Debts that haven’t been collected – even after several attempts. Examples of bad debt: accounts that are more than 180 days late and are sent to collection agencies, bankruptcy, death and sometimes charity or indigent care, small balances and accounts that can’t be collected due to incorrect addresses. Credits or write-offs are made to decrease the policyholder’s accounts receivable balance, although the policyholder still owes the debt.
Bad-Debt Write-off: Cancelling or removing a balance from an account after several unsuccessful attempts to collect. The balance is written off as bad debt. This doesn’t, however, dismiss responsibility for payment. A collection agency may be assigned to collect this debt from the policyholder.
Balance: What you owe for this service after your insurance organization(s) paid its part.
Balance On This Charge: The amount that’s owed for one particular service.
Capitation: The fee an insurance organization periodically pays to a health care provider or facility for medical services for each insured person under contract — whether or not that person receives medical service. Usually providers are paid a per-member, per-month fee to accept these patients or provide this type of service to patients.
Charge Amount: The amount your health care provider charged for this one service.
Charges: Debt incurred for medical service a health care provider or medical facility provided.
Claim: A form submitted to the insurance organization for payment of benefits. Either you or your health care provider can file your claim.
Code: The medical industry’s standard code that identifies the medical service.
Co-Insurance: The part (usually a percentage) of the covered health care cost for which you are financially responsible. Often, co-insurance applies after you meet your deductible.
Collection Write-off: Cancelling or removing a balance from an account after several unsuccessful attempts to collect and finally turning it over to a collection agency for collection. The balance is written off the account. This doesn’t, however, dismiss responsibility for payment. The policyholder is still responsible for paying, although the balance has been removed or cancelled from the account.
Coordination of Benefits: How insurance organizations determine the primary payment source when you’re covered under more than one insurance organization or group medical plan. Your insurance contract states that if you are covered under more than one insurance plan, benefits will be coordinated so that total benefits paid will not be more than 100% of the bill.
Co-Payment: The contractual provision that requires you to pay a specific charge for a specific service, usually when you receive the service. A co-payment usually applies to office visits, prescriptions, emergency or hospital services.
Covered Services: Specific services or supplies for which your insurance reimburses you or pays your health care provider. These consist of a combination of mandatory and optional services – and vary by state.
Deductible: The agreed amount you must pay before your insurance organization will pay a claim or reimburse you. Usually, you have 12 months to meet your deductible; eligible expenses after you meet your deductible are then paid for the rest of that 12-month period.
Disallowed Amount: The difference between the charge and the amount your insurance organization approves. If your health care provider is under contract with your insurance organization to accept the approved amount, you aren’t billed for the difference. If your provider is not under contract, you may be billed for this difference.
Due Date: When your payment is due; after this, it’s past due.
Group Number: The number of your insurance organization group. See your insurance card.
Guarantor: The person responsible for paying this bill.
Health Care Provider: A physician, specialist, medical group or facility that offers medical services.
Ineligible Expense: A charge your insurance organization won’t pay because it isn’t covered by your insurance plan.
Limit of Allowance (LOA): The difference between what your insurance organization approves and your health care provider charges for a procedure. (Also called a contractual allowance.) You’re not billed for this difference when your health care provider is under contract to accept your insurance organization’s approved amount. This difference shows up on your account as an account adjustment, decreasing the balance.
Non-Participating Health Care Provider: A health care provider who isn’t under contract with an insurance organization to accept patients and receive the insurance organization’s approved amount on all claims. (You pay the difference between its approved amount for a service and this health care provider’s charge.)
Participating Health Care Provider: A health care provider who contracts with an insurance organization to accept patients and receive the insurance organization’s approved amount on all claims.
Patient Statement: A statement showing what part of the charge, if any, you are responsible for paying.
Place of Service: The facility where service was performed.
Policy Number: The number on your insurance policy. See your insurance card.
Policyholder: The name of the person who “took out” or purchased the insurance policy; this person “owns” the policy; also called a subscriber or guarantor.
Pre-Authorization/Pre-Certification: The process of getting permission from your insurance organization for certain services before they are provided so that the services can be considered eligible expenses. Usually required for hospital and out-patient services.
Primary Insurance: The insurance organization with first responsibility for paying eligible insurance expenses for your medical service (after you’ve paid your deductible, co-payments, etc.). Your secondary or other insurance (if you have other insurance) would work with your primary insurance organization to cover eligible expenses according to your insurance policies.
Referral: Written authorization from your health care provider to see another health care provider. For example, your primary care provider may provide written authorization for you to see a specialist.
Secondary Insurance: The insurance organization with second responsibility for paying eligible insurance expenses for your medical service (after you’ve paid your deductible, co-payments, etc.). This insurance (if you have it) would work with your primary insurance organization to cover eligible expenses according to your insurance policies. This insurance organization is billed second — after your primary insurance organization has been billed.
Service Description: A word description, in billing office language, that identifies the medical service performed by your health care provider.
Subscriber: The person who purchases the insurance. Also known as a policyholder or guarantor.
Tertiary Insurance: The insurance organization with third responsibility for paying eligible insurance expenses for your medical service (after you’ve paid your deductible, co-payments, etc.). This insurance (if you have it) would work with your primary and secondary insurance organizations to cover eligible expenses according to your insurance policies. This insurance organization is billed third — after your primary and secondary insurance organizations have been billed.
Transaction Description: The result of activity – whether a service was billed, paid or put on your statement for you to pay.
Units: How many of a particular type of service you received.
Write-off: Cancellation or removal of claims or debts from an open account. This doesn’t necessarily dismiss responsibility for payment. A collection agency may be assigned to collect the debt from the policyholder.