Medical Billing Glossary

The maximum amount a plan will pay for a covered health care service. May also be called "eligible expense" or "payment allowance."

A request for your health insurer or plan to review a decision or a grievance again.

The person who is covered by the health insurance policy.

Codes used on the remittance advice to explain why a claim was paid differently than billed. Mandated by HIPAA.

A third-party company that acts as an intermediary between the provider and the payer, formatting claims data to meet HIPAA standards.

The standard claim form used by non-institutional providers and suppliers to bill Medicare carriers and DMERCs.

The process of determining which of two or more insurance policies will have the primary responsibility of processing/paying a claim.

The percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible.

A fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.

A medical code set maintained by the AMA to describe medical, surgical, and diagnostic services.

The amount you pay for covered health care services before your insurance plan starts to pay.

A statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf.

An electronic version of a medical insurance payment explanation. It provides details about providers' claims payment, and if the claims are denied, it offers explanations.

A set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (CPT).

International Classification of Diseases, 10th Revision. A system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms and procedures.

A unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS).

Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered.

Codes used to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC).

The standard claim form used by institutional providers (hospitals, SNFs) to bill payers.

The difference between the provider's standard fee and the allowed amount contracted with the insurance carrier; this amount is adjusted off the patient's account.