SJE Billing Glossary
Account Number -
Number you're given for each hospial visit.
Actual Charge -
The amount of money a doctor or supplier charges for a certain medical service
or supply. This amount is often more than the amount an insurance plan approves.
Adjustment - The
portion of your bill that your doctor or hospital has agreed not to charge
Admission Date -
Date you were admitted for treatment.
Diagnosis - Words that your doctor uses to describe your condition.
Advance Beneficiary Notice
(ABN) - A notice the hospital or doctor gives you before you're
treated, telling 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.
(Healthcare) - Written ahead of time, a health care advance directive
is a written document that says how you want medical decisions to be made if you
lose the ability to make decisions for yourself. A health care advance directive
may include a Living Will and a Durable Power of Attorney for health care.*
- Payment covering all services during your hospital stay.
Ambulatory Care -
All types of health services that do not require an overnight hospital
- Outpatient surgery or surgery that does not require an overnight hospital
Amount Charged -
how much your doctor or hospital bills you.
Amount Paid -The
dollar amount that you paid for your doctor or hospital visit.
Amount Not Covered
- What your insurance company does not pay. It includes deductibles,
co-insurances, and charges for non-covered services.
Amount Payable by
Plan - How much your insurer pays for your treatment, minus any
deductibles, coinsurance, or charges for non-covered services.
- Services you need beyond room and board charges, such as laboratory tests,
therapy, surgery and the like.
Anesthesia - Drugs
given to you during surgery to eliminate or reduce surgical procedure pain.
Appeal - 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 not pay for your care.
Deductible - Portion of your bill, as defined by your insurance
company, that you owe your doctor or hospital.
Assignment - An
agreement you sign that allows your insurance to pay the doctor or hospital
Benefits - When insurance payments are sent directly to your doctor or
Name - The doctor who certifies that you need treatment and is
responsible for your care.
Number - A number stating that your treatment has been approved by your
insurance plan. Also called a Certification Number or Prior-Authorization
Balance Bill - How
much doctors and hospitals charge you after your health plan, insurance company,
or Medicare have paid its approved amount.
Person covered by health insurance.
Benefit - The
amount your insurance company pays for medical services.
Bill/Invoice/Statement - Printed summary of your
Case Management -
A way to help you get the care you need, especially when you need pre-authorized
care from several services. Usually a nurse helps arrange for your care.
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 program. CMS works to
make sure that the beneficiaries in these programs are able to get high quality
Charity Care -
Free or reduced-fee care for patients who have financial hardship.
Claim - Your
medical bill that is sent to an insurance company for processing.
Claim Number - A
number given to a medical service.
COBRA Insurance -
Health insurance that you can buy when you lose your job. It is generally more
expensive than insurance provided through your job but less expensive than
insurance purchased on your own when you are unemployed.
Coding of Claims -
Translating diagnoses and procedures in your medical record into numbers that
computers can understand.
Coinsurance - The
cost sharing part of your bill that you have to pay.
- A business that collects money for unpaid bills.
treatment) - An agreement you sign that gives your permission to
receive medical services or treatment from doctors or hospitals.
Adjustment - A part of your bill that your doctor or hospital must
write off (not charge you) because of billing agreements with your insurance
Coordination of Benefits
(COB) - A way to decide which insurance company is responsible for
payment if you have more than one insurance plan.
Co-pay - Agreed
amount of the charges for medical services that patients or guarantors must
Covered Benefit -
A health service or item that is included in your health plan, and that is paid
for either partially or fully.*
Covered Days -
Days that your insurance company pays for in full or in part.
CPT Codes - A
coding system used to describe what treatment or services were given to you by
Date of Bill - The
date the bill for your services is prepared. It is not the same as the date of
Date of Service
(DOS) - The date(s) when you were treated.
Deductible - How
much cost sharing that you must pay for medical services often before your
insurance company starts to pay.
Services - Tells what your doctor or hospital did for you.
Diagnosis Code - A
code used for billing that describes your illness.
Related Groups (DRGs) - A payment system for hospital bills. This system
categorizes illnesses and medical procedures into groups for which hospitals are
paid a fixed amount for each admission.
Hour when you were discharged.
Discount - Dollar
amount taken off your bill, usually because of a contract with your hospital or
doctor and your insurance company.
Administered - Drugs that do not require doctors or nurses to help you
when you take them. You may be charged for these. You will need to check with
your doctor or hospital regarding their policy on this.
Due from Insurance
- How much money is due from your insurance company.
Due from Patient -
How much you owe your doctor or hospital.
Durable Medical Equipment
(DME) - Medical equipment that can be used many times, or special
equipment ordered by your doctor, usually for use at home.
EEG - Equipment or
medical procedure that measures electricity in the brain.
Equipment or medical procedure that measures how your heart works, and your
doctor's reading of the results.
Amount - Those medical services that an insurance company pays for.
Emergency Care -
Care given for a medical emergency when you believe that your health is in
serious danger when every second counts.*
Emergency Room - A
special part of a hospital that treats patients with emergency or urgent medical
Insurance - Estimated cost paid by your insurance company.
Enrollee - A
person who is covered by health insurance.
Due - How much the doctor or hospital estimates you or your insurance
Explanation of Benefits
(EOB/EOMB) - 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.
Federal Tax ID
Number - A number assigned by the federal government to doctors and
hospitals for tax purposes.
Responsibility - How much of your bill you have to pay.
(FI) - A Medicare agent that processes Medicare claims.
Fraud and Abuse -
Fraud: To purposely bill for services that were never given or to bill for a
service that has a higher reimbursement than the service produced. Abuse:
Payment for items or services that are billed by mistake by providers, but
should not be paid for by the insurance plan. This is not the same as
Someone who has agreed to pay the bill.
HCFA 1500 Billing Form
(CMS) - A form used by doctors to file insurance claims for medical
HCPC Codes - A
coding system used to describe what treatment or services were given to you by
Provider - Someone who provides medical services, such as doctors,
hospitals, or laboratories. This term should not be confused with insurance
companies that "provide" insurance.
Health Insurance -
Coverage that pays benefits for sickness or injury. It includes insurance for
accidents, medical expenses, disabilities, or accidental death and
Organization (HMO) - An insurance plan that pays for preventive and
other medical services provided by a specific group of participating
HIPAA - Health
Insurance Portability and Accountability Act. This federal act sets standards
for protecting the privacy of your health information.
Home Health Agency
- An agency that treats patients in their homes.
Hospice - Group
that offers inpatient, outpatient, and home healthcare for terminally ill
Charge - Charges for nursing services added to basic room and board
Inpatient (IP) -
Patients who stay overnight in the hospital.
Name - Name of the company that your claim will be sent to.
Insured Group Name
- Name of the group or insurance plan that insures you, usually an employer.
Number - A number that your insurance company uses to identify the
group under which you are insured.
(Beneficiary) - The name of the insured person.
Intensive Care -
Medical or surgical care unit in a hospital that provides care for patients who
need more care than a general medical or surgical unit can give.
Internal Control Number
(ICN) - A number assigned to your bill by your insurance company or
IV Therapy -
Treatment provided by giving intravenous solutions or drugs.
Labor and Delivery
Room - A unit of a hospital where babies are born.
Charges for blood tests and tests on body tissue samples, such as biopsies.
Long-Term Care -
Care received in a nursing home. Medicare does not pay for long-term care unless
you need skilled nursing or special rehabilitation.
Account - A monthly summary of services (and charges?) mailed to the
person who pays the bill.
Managed Care - An
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
Medicaid - A state
administered, federal and state funded insurance plan for low-income people who
have limited or no insurance.
Number - The number assigned by your doctor or hospital that identifies
your individual medical record.
Supplies - Special supplies, such as materials used to repair a wound
or instruments used for your care.
Medicare - A
health insurance program for people age 65 and older. Medicare covers some
people under age 65 who have disabilities or end-stage renal disease (ESRD).
Medicare + Choice
- A Medicare HMO insurance plan that pays for preventive and other healthcare
from designated doctors and hospitals.
- Medical services for which Medicare normally pays.
Assignment - Doctors and hospitals who have accepted Medicare patients
and agreed not to charge them more than Medicare has approved.
Medicare Number -
Every person covered under Medicare is assigned a number and issued a card for
identification to providers.
Medicare Paid -
The amount of your bill that Medicare paid.
Provider - The amount of your bill that Medicare paid to your doctor or
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 Summary Notice
(MSN) - The notice you receive from Medicare after getting services
from your doctor or hospital. It tells you what was billed to Medicare,
Medicare's approved payment, the amount Medicare paid, and what you have to pay.
Also called an Explanation of Medicare Benefits (EOMB).
Medigap - Medicare
Supplement Insurance that pays for some services not covered by Medicare A or B,
including deductible and coinsurance amounts.
MRI - A type of
X-ray; magnetic resonance brain or body images, usually done in a hospital's
Network - A group
of doctors, hospitals, pharmacies, and other health care experts hired by a
health plan to take care of its members.*
Charges - Charges for medical services denied or excluded by your
insurance. You may be billed for these charges.
Provider - A doctor, hospital, or other healthcare provider that is not
part of an insurance plan's doctor or hospital network.
Nursery - Nursing
care charges for newborn babies.
Observation - Type
of service used by doctors and hospitals to decide whether you need inpatient
hospital care or whether you can recover at home or in an outpatient area.
Usually charged by the hour.
Provider - A doctor or other healthcare provider who is not part of an
insurance plan's doctor or hospital network. Same as non-participating
Costs - Costs you must pay because Medicare or other insurance does not
Outpatient (OP) -
Patient who does not need to stay overnight in a hospital. Outpatient services
include lab tests, x-rays, and some surgeries.
- A service you receive in one day at a hospital or clinic without staying
Drug - Drugs not needing a prescription that you buy at a pharmacy or
Paid to Provider -
Amount the insurance company pays your medical provider.
Paid to You -
Amount the insurance company pays you or your guarantor.
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 Amount Due
- The amount charged by your doctor or hospital that you have to pay.
Pay This Amount
-How much of your bill you have to pay.
Per Diem - Charged
or paid by the day.
Pharmacy Charges -
Cost of drugs given under a pharmacist's direction.
Physical Therapy -
Treatment of diseases or injuries by exercise, heat, light, and/or massage.
Physician - Person
licensed to practice medicine.
- A group of doctors, nurses, and physician assistants who work
Management - Non-physician staff hired to manage the business aspects
of a physician practice. These staff include billing staff, medical records
staff, receptionists, lab and X-ray technicians, human resources staff, and
(POS) - An insurance plan that allows you to choose doctors and
hospitals without having to first get a referral from your primary care
Policy Number - A
number that your insurance company gives you to identify your contract.
Pre-Admission Approval or
Certification - An agreement by your insurance company to pay for your
medical treatment. Doctors and hospitals ask your insurance company for this
approval before providing your medical treatment.
Condition - A health condition or medical problem that you already have
before you sign up to receive insurance. Some health insurers may not pay for
health conditions you already have.
Money you pay before getting medical care; also referred to as preadmission
- A billing charge that is commonly made by doctors in a specific region or
community. Your insurance company determines this charge.
Primary Care Network
(PCN) - A group of doctors serving as primary care doctors.
Primary Care Physician
(PCP) - A doctor whose practice is devoted to internal medicine,
family/general practice, or pediatrics. Some insurance companies consider
Obstetrician/gynecologists primary care physicians.
Company - The insurance company responsible for paying your claim
first. If you have another insurance company, it is referred to as the Secondary
(Deluxe) - A more expensive hospital room than those available to other
patients. You may have to pay extra for this type of room if it is not a medical
Procedure Code (CPT
Code) - A code given to medical and surgical procedures and
Discount - A part of your bill that your doctor or hospital must write
off (not charge you) because of billing agreements with your insurance
Provider Name, Address, and
Phone # - Name and address of the doctor or hospital submitting your
Radiology - X-rays
used to identify and diagnose medical problems.
Reasonable and Customary (R
& C) - Billing charges that insurers believe are appropriate for
services throughout a region or community.
Recovery Room - A
special room where you are taken after surgery to recover before being sent home
or to your hospital room.
Approval needed for care beyond that provided by your primary care doctor or
hospital. For example, managed care plans usually require referrals from your
primary care doctor to see specialists or for special procedures.
Information - A signed statement from patients or guarantors that
allows doctors and hospitals to release medical information so that insurance
companies can pay claims.
Therapy - Giving oxygen and drugs through breathing, as well as other
therapies that measure inhaled and exhaled gases and blood samples.
- The person(s) responsible for paying your hospital bill--usually referred to
as the guarantor.
Revenue Code - A
billing code used to name a specific room, service (X-ray, laboratory), or
Room and Board
Private - Routine charges for a room with one bed.
Room and Board
Semiprivate - Routine charges for a room with two beds.
Same-Day Surgery -
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.
Service Area -
Geographic area where your insurance plan enrolls members. In an HMO, it is also
the area served by your doctor network and hospitals.
Service Begin Date
- The date your medical services or treatment began.
Service Code - A
code describing medical services you received.
Service End Date -
The date your medical services or treatment ended.
Facility - An inpatient facility in which patients who do not need
acute care are given nursing care or other therapy.
Specialist - A
doctor who specializes in treating certain parts of the body or specific medical
conditions. For example, cardiologists only treat patients with heart
Submitter ID -
Identification number (ID) that identifies doctors and hospitals who bill by
computers. Doctors and hospitals get an ID from each insurance company to whom
they send claims using the computer.
Company - An additional insurance policy that handles claims for
deductible and coinsurance reimbursement.
Total Charges -
Total cost of your medical services.
Type of Admission
- The reason for your admission, such as emergency, urgent, elective, etc.
Type of Bill - A
bill that shows what type of care is being billed, such as hospital inpatient,
hospital outpatient, skilled nursing care, etc.
UB-92 - A form
used by hospitals to file insurance claims for medical services.
Units of Service -
Measures of medical services, such as the number of hospital days, miles, pints
of blood, kidney dialysis treatments, etc.
(UR) - Hospital staff who work with doctors to determine whether you
can get care at a lower cost or as an outpatient.
You May be Billed
- A phrase used by your insurance company informing you that your doctor or
hospital may bill some charges directly to you.