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Glossary
Definitions of Important Terms
-A-
Account - The number you are given by your Ambulance Provider for a medical visit.
Adjustment - The portion of your bill that the Ambulance Provider has agreed not to charge you.
Advance Beneficiary Notice (ABN) - A notice the Ambulance Provider gives you before you are treated explaining to you that Medicare will not pay for some treatment or services. The notice is given to you so that you may decide whether to have the treatment and how to pay for it.
ALS - Advanced Life Support Services, Medic Unit with trained Paramedics
Ambulance - Describes the service location for services received in connection with an ambulance transport; or services performed by an ambulance company, EMT company, or fire or rescue squad.
Appeal - A process by which you, your Ambulance Provider can object to your health plan when you disagree with the health plan's decision not to pay for your care.
Approved Amount - The amount of the Ambulance Provider's charge that a payer will recognize in calculating benefits. (Under Medicare, also called "Medicare Allowable Charge")
Adjustment: indicates that an adjustment has been made to the original claim.
-B-
Beneficiary - Person covered by health insurance.
Benefit - The amount your insurance company pays for medical services.
Billed Amount - The dollar amount billed for a specific healthcare service.
BLS - Basic Life Support Services, Ambulance with trained Emergency Medical Technicians/ EMTS.
-C-
Check Date - This is the date the check was issued and mailed. If no payment was made on the claim, this is the date the member's Explanation of Benefits (EOB) and clinician's Voucher were issued and mailed.
Claim Number - The claim number is the unique number that identifies this claim in the claim system. It is displayed primarily for informational purposes here, though it may be of assistance if you have reason to contact Customer Service with a question on this claim.
Claim Status - This display describes the claim processing status in the claim system.
Complete: indicates that the claim has been completed or closed.
Co-insurance - The cost sharing part of the bill that you have to pay. For Medicare, the percent of the approved charge that you have to pay either after you pay the Part A deductible, or after you pay the first $100 deductible each year for Part B.
Contracting - Refers to a participating or network clinician.
Coordination of Benefits (COB) - A way to decide which insurance company is responsible for payment if you have more than one insurance plan.
Contractual Adjustment - A part of your bill that your Ambulance Provider must write off(not charge you) because of billing agreements with your insurance company.
Co-payment - A type of cost sharing whereby the insured person pays a specified flat amount per unit of service or unit of time (e.g., $10 per visit, $25 per inpatient hospital day), with the insurer paying the balance.
CPT codes - A coding system used to describe what treatment or services were given to you by your doctor.
-D-
Date of Service (DOS) - The date(s) when you were treated.
Deductible - The amount you must pay for medical services before your insurance company begins to pay.
Deductible - Family The amount of an eligible expense a covered family must pay annually before the plan will make payment for eligible benefits.
Deductible - Individual The amount of an eligible expense a member must pay annually before the plan will make payment for eligible benefits.
Diagnosis Code - A code used for billing that describes your illness.
DOA - Dead on arrival.
DOB - Date of birth.
DOS - Date of service.
-E-
ER - Emergency Room
EMS - Emergency Medical Services, both BLS and ALS.
Explanation of Benefits (EOB) - The notice you receive from your insurance company after getting medical services from a doctor or hospital. It tells you what was billed, the payment amount approved by your insurance, the amount paid, and what you have to pay.
-G-
Guarantor - Someone who has agreed to pay the bill.
-H-
HCPCS - Healthcare common procedure coding system.
HIPAA - Health Insurance Portability and Accountability Act. This federal acts sets standards for protecting the privacy of your health information.
-I-
ICD9 - The insurance industry name for a commonly used reference, International Classification of Diseases, 9th Edition. This is a listing of diagnosis or identifying codes used to report the condition of patients who have received healthcare services. This is the standard used by healthcare clinicians and payors throughout the United States.
In Process: indicates that the claim is currently being processed.
In Network - Services received within the authorized service area from a participating clinician that is contracted.
Inpatient - Describes services for individuals who have been admitted to a hospital as registered patients and have received hospital care for at least 24 hours.
Inpatient Hospital - The service location for individuals who have been admitted to a hospital as registered patients and have received hospital care for at least 24 hours.
Insured - The person who carries the insurance with , also called the employee or subscriber.
-L-
License - An official permit issued by a state to an individual authorizing them to perform health care services.
-M-
Managed Care Plans - A insurance plan that requires patients to see doctors and hospitals that have a contract with the managed care company, except in the case of medical emergencies or urgently needed care if you are out of the plan's service area.
Medical Record Number - The number assigned by your Ambulance Provider that identifies your individual medical record.
Medicare Assignment - Ambulance Providers who have accepted Medicare patients and agreed not to charge them more than Medicare has approved.
Medicare Part A - Usually referred to as Hospital insurance, it helps pay for inpatient care in hospitals and hospices, as well as some skilled nursing costs.
Medicare Part B - Helps pay for doctor services, outpatient care and other medical services not paid for by Medicare Part A.
Medicare Medical Savings Account - A Medicare health plan option made up of two parts. One part is a Medicare MSA Health Policy with a high deductible. The other part is a special savings account, called a Medicare MSA.
Member - Any person covered by a insurance policy.
Member Responsibility - The total dollar amount owed by the member or responsible party for this service. This will include any copay, billed amounts over the UCR, charges for non-covered services or other disallowed amounts applied to this service.
-N-
No Coverage - We are unable to find your benefits at this time. Either you don't have the specified coverage or your benefits are in the process of being setup.
Non-Covered Charges - Charges for medical services denied or excluded by your insurance. You may be billed for these charges.
Non-Participating Provider - A doctor, hospital or other healthcare provider that is not part of an insurance plan's doctor or hospital network.
NPI (National Provider Indicator) - A 10 digit number used to identify covered providers on all HIPAA covered transactions.
-O-
OIG - Office of the inspector general.
Original Medicare Plan - The traditional pay-per-visit arrangement that covers Part A and Part B services.
Out-of-Network Provider - A doctor or other healthcare provider who is not part of an insurance plan's doctor or hospital network. Same as non-participating provider.
Outpatient - Describes services for individuals who receive healthcare services at a hospital clinic or outpatient department but are not admitted as registered patients.
-P-
Paid Amount - The amount has paid for a particular healthcare service.
Participating Provider - A doctor or hospital that agrees to accept your insurance payment for covered services as payment in full, minus your deductibles, co-pays and coinsurance amounts.
Patient - The person who received mental healthcare services.
Patient Type - A way to classify patients - outpatient, inpatient, etc.
PCR - Patient care report.
PCS - Physician certification statement.
Point of Service Plan (POS) - An insurance plan that allows you to choose doctors and hospitals without having to first get a referral from your primary care doctor.
Primary Insurance Company - The insurance company responsible for paying your claim first. If you have another insurance company, it is referred to as the Secondary Insurance Company.
Private Fee-for-Service Plan - A private insurance plan that accepts Medicare beneficiaries.
Procedure Code (CPT) - A code given to medical and surgical procedures and treatments.
Provider - An individual licensed to provide healthcare services.
Pending: indicates that the claim has been entered into the system but is pending review or check write.
-R-
Referral - Permission from your primary care doctor to see a certain specialist or receive certain services.
Remark Code - A remark code is used when some explanation is helpful in understanding how a claim or service on a claim has been processed. Each Remark has an explanation that will be displayed at the bottom of the claim detail window.
Responsible Party - The person(s) responsible for paying your hospital bill--usually referred to as the guarantor.
-S-
Secondary Insurance - Extra insurance that may pay some charges not paid by your primary insurance company. Whether payment is made depends on your insurance benefits, your coverage and your benefit coordination.
Skilled Nursing Facility (SNF) - An inpatient facility in which patients who do not need acute care are given nursing care or other therapy.
SOB – Shortness of breath.
Subscriber - The person who carries the insurance with , also called the insured.
Supplemental Insurance Policy - An additional insurance company that handles claims for deductibles and coinsurance reimbursement. Many private insurance companies sell Medicare Supplemental Insurance.
-T-
Third Party Billing - Submission of an ambulance bill to your primary / secondary insurance carriers on your behalf for reimbursement of ambulance expenses to the patient or to CHFD-EMS. This procedure applies to members and non-members. Members have no out of the pocket expenses after payment by the insurance carrier[s]. Non-members are individually responsible for any unpaid balances.
-U-
UCR - Short for Usual, Customary and Reasonable, UCR is a set of commonly billed rates for standard services in specific geographic regions. Based on zip code areas, UCR rates are reviewed on April 1 and October 1 of each year. uses UCR rates to establish the covered amount for services received by clinicians not in the network. As a rule, billed amounts in excess of the UCR rate will be the responsibility of the member.
UTA - Unable to obtain.
Unit - The unit tells us the number of times the service was performed on each date.
Urgently Need Care - Unexpected illness or injury that needs immediate medical attention, but is not life threatening.
Utilization Review (UR) - Hospital staff who work with doctors to determine whether you can get care at a lower cost or as an outpatient.
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