Glossary
837I |
The electronic UB-04 |
AAPC | American Academy of Professional Coders |
A/R |
Accounts Receivable |
ABN | An ABN (Advanced Beneficiary Notice) is designed to notify the beneficiary, before items and/or services are furnished, as to why Medicare may deny payment. |
ABN L |
Advance Beneficiary Notice Lab |
Above–Threshold ePHI System | A system that creates accesses, transmits or receives: 1) primary source ePHI, 2) ePHI critical for treatment, payment or health care operations or 3) any form of ePHI and the host system is configured to allow access by multiple people. Examples include:A personal computer with a Microsoft Access database containing ePHI that is configured to allow access by more than one person, a departmental server with file shares containing ePHI, a computer system used to create, access, transmit or receive ePHI that is configured to allow access by a non–associated vendor/contractor, a clinical care system which contains primary source ePHI, or a billing system that is critical to clinical care operations. |
Abuse |
Unintentional mistake or accident |
ACA | The Patient Protection and Affordable Care Act, for short, the Affordable Care Act, is a Federal Statute signed by President Barak Obama in 2010. Commonly referred to as Obamacare |
Accounting of Disclosures | The Privacy Rule grants to a patient a right to request and receive an accounting for some “disclosures” of PHI, including disclosures made in connection with certain research projects. An accounting is a record of each disclosure of each patient’s PHI. A right to an accounting only applies to disclosures of PHI, not to uses of PHI. Patients have a right to an accounting only of those disclosures made by researchers in connection with protocols conducted with a waiver of authorization. An accounting of disclosures is not required when a patient authorization is obtained. |
Aden |
Gland |
ADL |
Activities of Daily Living |
ADR | Additional Documentation Request |
AGI |
Adjusted Gross Income |
AIDS |
Acquired immune deficiency syndrome. Disorder caused when HIV damages the immune system, leaving the person open to kinds of infections that other people rarely get or fight off easily. |
AGB |
Abbreviation for Amount Generally Billed |
AGB Percentage | A percentage of gross charges that a hospital facility uses to determine the AGB for any emergency or other medically necessary care it provides to an individual who is eligible for assistance under its financial assistance policy (FAP). |
ASC |
Ambulatory Surgery Classification |
AHIMA | American Health Information Management Association |
AHI QA | AHI QA (Quality Assurance) is a web-based system designed to help you identify errors in registration records and make corrections before they impact your cash flow and other revenue cycle processes. |
AHRQ |
Agency for Healthcare Research and Quality |
AIDET |
Acknowledge, Introduce, Duration, Explanation, Thank You |
ALJ |
Administrative Law Judge |
Allowable Charge | The maximum fee that a third party will reimburse a provider for a given service. |
Allowable Costs | Items or elements of an institution's costs that are reimbursable under a payment formula. Allowable costs may exclude, for example, uncovered services, luxury accommodations, costs that are not reasonable, and expenditures that are unnecessary. |
AMA |
American Medical Association |
AMI |
Acute Myocardial Infarction |
APC |
Ambulatory Payment Classification |
Appeal |
An application or proceeding for review by a higher tribunal |
Application of Financial Assistance |
The form used to determine financial need according to a hospital Financial Assistance Policy (FAP). |
Application Period | As relating for FAP regulation, the time during which a hospital facility must accept and process an application for financial assistance under its FAP submitted by an individual in order to have made reasonable efforts to determine whether the individual is FAP-eligible |
Arthro |
Prefix meaning or relating to the joint |
Audit |
an official examination and verification of accounts and records, esp. of financial accounts. |
Balance Billing |
The practice of billing a patient for the amount remaining after the insurer payment and co-payment has been made. For example, a physician may charge $100 for an office visit and if the insurance company only reimburses the doctor $85, the patient would be billed the additional balance of $15 by the physician. This practice is usually not allowed under most HMOs, but is dependent on the contractual arrangement between the healthcare provider and the health plan. |
Basic ePHI System | A system that is typically used by a single individual and is used to create, access, transmit or receive ePHI. However, s System, even if used only by a single user, which supports primary source ePHI or ePHI critical for treatment, payment or health care operations is an Above threshold System. See also Above–Threshold ePHI systems. Business Associate: Generally an entity or person who performs a function involving the use or disclosure of Protected Health Information (PHI) on behalf of a covered entity (such as claims processing, case management, utilization review, quality assurance, billing) or provides services for a covered entity that require the disclosure of PHI (such as legal, actuarial, accounting, accreditation). |
BAT |
Blood Alcohol Test |
BCBS | Blue Cross Blue Shield |
Beneficiary |
Any person who has coverage under a health insurance plan. |
BIPA | Benefit Improvement and Protection Act of 2000 |
Bloodborne Infections |
Viruses or diseases spread by contact with blood. |
Burn Out |
Prolonged and unrelenting stress |
CAH |
Critical Access Hospital |
Care Management | Sometimes less appropriately called case management or utilization management. Helps achieve better health outcomes by anticipating and linking patients with the services they need more quickly. Care management also helps to avoid unnecessary testing and care by preventing medical problems from escalating. |
Care Paths | Set forth the steps that should be taken to assure an optimal outcome for the patient based upon the diagnosis and other factors set forth in the care plan. |
Case Management | Case Management: The process whereby a health care professional supervises the administration of medical or ancillary services to a patient, typically one who has a catastrophic disorder or who is receiving mental health services. Case managers are thought to reduce the costs associated with the care of such patients, while providing high-quality medical services. |
CB |
Consolidated Billing |
CC |
Complication or co-morbidity |
CDC |
Centers for Disease Control and Prevention (CDC): The U.S. agency that tracks the spread of diseases. It developed the original Universal Precautions recommendations for controlling HBV and HIV in the workplace. It is a part of the U.S. Department of Health and Human Services. |
CERT |
Comprehensive Error Rate Testing |
CFO |
Chief Financial Officer HIS: Health Information System |
CHNA | Abbreviation for Commuity Health Needs Assessment |
Clearinghouse |
Responsible for the transmission of the claims from you to the payers. |
Clinic Referral | The patient was admitted or referred for OP services by your facilities clinic or other outpatient department physician. |
Closed Panel | A type of HMO in which the physicians are employed by the health plan and only see patients who are members of the HMO. |
Clostridium Difficile (C.diff) | A gram positive bacterium, that is capable of producing spores when conditions no longer support its continued growth. The ability to form spores allows the organism to remain in the environment for extended periods of time. |
CMS | Center for Medicare andMedicaid Services. Overseer of Section1011 program as well as Medicare and Medicaid |
CMS 1500 | The prescribed form for claims prepared and submitted by physicians and suppliers whether or not the claims are assigned. |
CNO | Chief Nursing Officer |
COBRA | Consolidated Omnibus Budget Reconciliation Act |
Coinsurance | Coinsurance is the percentage of allowed charges paid by the patient after deductible has been met after the insurance pays their portion. |
Commercial Carriers | Commercial carriers are generally national in their geographic scope and offer both group and individual plans. |
Concurrent Review |
A review that occurs during active management of a patient’s medical needs. |
Condition code | A two-digit numeric code that is entered on the UB-04 claim form to indicate that a condition applies to the bill that affects processing and payment of the claim |
Consolidated Payment | A packaged payment of a predetermined amount for specific services provided to Medicare patients. |
Copayment | A copayment is a specified dollar amount due at the time of service. This amount is dictated by service type and will not vary based on the actual cost of the services. |
Cost Sharing | Cost sharing: A broad term representing the ways in which a covered member shares in the cost of healthcare services with the health plan. Examples of this include deductibles, co-payments, and coinsurance. |
CPT | Current Procedural Terminology |
CPT Codes | Classifications of medical codes developed and maintained by the AMA. |
CPT/HCCPS | Current Procedural Terminology/Healthcare Common Procedure Coding System |
CPU | Central Processing Unit |
Creation date | The date you created a UB that you are submitting to the payer for payment |
CWF | Common Working File |
cardio | heart |
CCI | Correct Coding Initiative |
CE | Covered Entity |
cephal | head |
cerebro | brain |
CERT | Comprehensive Error Rate Testing |
Chemotherapy | The use of chemical substances to treat disease. |
CHIP | Children's Health Insurance Program |
claim | A request or demand for payment in accordance with an insurance policy |
Clinic | A location that furnishes medical and health services. |
CMD | Case Management Department |
CMO | Care Management Organizations |
CMP | Civil money penalty |
Concurrent | Occurring at the same time as another infusion or injection. |
Condition code | A code used to identify conditions relating to a bill that may affect payer processing. |
Consent | Giving permission |
Consistency | Performing a service or procedure in a logical manner the same way each time with no variations in the process. |
cysto | bladder |
DAS | Disability Adjudication Services. Specialized program of Rehabilitation Services and works with the Social Security Administration to make disability determinations for Georgia citizens who apply for entitlement programs administered by the Social Security Administration. |
DCH | Department of Community Health |
DCN | Document Control Number |
DED | Dedicated Emergency Department: Any department or facility of the hospital that either: 1. is licensed by the State as an emergency department; 2. held out to the public as providing treatment for emergency medical conditions (name, signs, advertising); or 3. at least one third of the visits to the department in the preceding calendar year actually provided treatment for emergency conditions on an urgent basis. |
Deductible | Deductible: Amount that must be paid prior to receiving medical benefits from a health plan. This is most often associated with PPOs and indemnity companies and can vary from $100 to as high as $2,500 or more. Office visit co-payments are usually paid regardless of whether or not the deductible has been met. Usually, the deductible is based on the calendar year. |
Definitive Policy | A definitive policy list specific signs and symptoms that are designated by a list of specific ICD-9 codes. |
DHHS | Department of Health and Human Services |
Diagnostic Service | An exam or procedure used to identify a patient’s problem or illness |
Disallowance | This occurs when an insurance company or health plan denies payment for certain benefits. For example, if a claim is submitted for teeth whitening, it may be disallowed because of the cosmetic nature of the procedure. |
Discharge | To release from a hospital facility after the care at issue has been provided, regardless of whether that care has been provided on an inpatient or outpatient basis. Thus, a billing statement for care is considered “post-discharge” if it is provided to an individual after the care has been provided and the individual has left the hospital facility |
DME | Durable Medical Equipment. Medical equipment which can withstand repeated use, is appropriate for use in the home and serves a medical purpose. |
DRG | Diagnosis-related Group |
DSH | Disproportionate Share Hospital |
DX | Diagnosis |
DX Code | A diagnosis code (DX) is an alphanumeric code that describes the patient’s medical condition, symptoms, or the reason for the encounter |
DAB | Departmental Appeals Board |
Decubiti | Decubitus, bed sore |
denial | the act of refusing to comply |
derm | skin |
descriptive | Describing shape, size, function, color etc. |
DOB | Date of Birth |
DVT | Deep Vein Thrombosis |
ECA | Abbreviation for Extraordinary Collection Action |
ED | Emergency Department |
EDI | Electronic Data Interchange |
EFT | Electronic Funds Transfer |
EIA Test | Enzyme Immunoassay Test is the most common test used for C.diff by laboratories |
Empathy | The ability to think from another person's perspective in order to understand reactions and behavior. |
Emergency Medical Care | Care provided by a hospital facility for emergency medical conditions |
EMR | Electronic Medical Record |
eponyms | “putting a name upon” |
ER | Emergency Room |
Electronic Claims Processing | A claim submitted by a provider or electronic media claim (EMC) vendor via central processing unit (CPU) to CPU transmission, tape, diskette, direct data entry, direct wire, dial-in-telephone, digital fax, or personal computer upload or download. |
EMTALA | Emergency Medical Treatment and Active Labor Act |
EOB | Explanation of Benefits |
EPO | Epoetin Alfa |
ER | Emergency Room |
ESRD | End Stage Renal Disease |
Estate | The total of a person’s property (including money), entitlements and obligations. |
Evaluation and Management code (E/M) | CPT codes that are reported in billing for hospital Emergency Room or clinic visits. |
Excluded Services | Services that can be billed directly to Medicare by providers. These are services not included in consolidated payments. |
Exclusions | Specific illnesses, injuries or methods of treatment that aren’t covered under an employee benefit plan. An example of this would be a pre-existing condition or a procedure, such as cosmetic surgery, that’s not medically necessary. |
Exclusive Provider Organization (EPO) | A term used to describe a health plan that is similar to an HMO in that it provides benefits only if the insured uses the specified network of providers, but is usually offered as an insured or self-funded product. EPOs usually mandate that coverage be channeled through a primary care physician. Also, EPOs are governed by the state’s Department of Insurance, as are PPOs, whereas most HMOs are governed under the Department of Commerce or the Department of Corporations, depending on specific state structures. |
Execution and levy | The execution of a money judgment is obtained through a legal process of enforcing the judgment by seizure and subsequent sale of the property owned by a judgment debtor. |
Exposure |
Contact with blood, body fluids, or tissue in a way that could allow HIV, HBV, or HCV to get into the body. |
External Customer | Non-employee people that we serve i.e. Patients, Community, Business Partners/Vendors |
FAP | Abbreviation for Financial Assistance Policy, it is a written policy that meets the requirements described in §501(r)–4(b). |
FAP Application |
The application form (and any accompanying instructions) that a hospital facility makes available for individuals to submit as part of a FAP application. |
FAP Eligible | A individual eligible for financial assistance under a hospital facility’s FAP for care covered by the FAP, without regard to whether an individual has applied for assistance under the FAP. |
FDCPA | Fair Debt Collection Practices Act |
FEP | Federal Employee Program |
FFS | Medicaid Fee for Service |
FI | Fiscal Intermediary |
FL | Form Locator |
FOCUS-PDCA | Find a process improvement opportunity, Organize a team which understands the process, Clarify the current knowledge of the process, Uncover the root cause of the variation or poor outcome, Start the ‘Plan-Do-Check-Act’ Cycle, Plan, Do, Check, Act |
Form Locator (FL) | Designated box on the UB-04 for codes required for billing. Each form locator is numbered and has a specific purpose. |
FPG | Federal Poverty Guidelines |
Fraud | Intentional deception or misrepresentation |
Frequency Limitation | Medicare only allows a test a certain number of times during a certain period. For example, a mammogram is allowed once a year. If a patient wants one 6 months after her last one, it isn't covered by Medicare and an ABN must be obtained that says the patient is responsible due to the frequency limitation. |
FTC | Federal Trade Commission |
FPE | Fiscal Period End |
GHA | Georgia Hospital Association |
Garnishment | Filed against a party as a means of collecting a judgment that has been entered. |
Gatekeeper | Refers to a primary care physician who controls referrals of patients for tests, specialty physician services and hospitalizations. Gatekeeper model: This is a model for an HMO in which the primary care physician (PCP) serves as the patient’s "gatekeeper," or initial contact for all health care. This is also referred to as "closed access" or a "closed panel." Most HMOs operate under the gatekeeper model, although many are now allowing patients to see some types of specialists, such as an ob/gyn or dermatology physician, without first going through their primary care physician. |
GDH Test | Glutamate Dehydrogenase Test detects antigen produced in high amounts by C.diff, both toxin and non-toxin producing strains. |
GHP | Group Health Plan |
Gross Charges | Commonly referred to as the charge master rate, means a hospital facility’s full, established price for medical care that the hospital facility consistently and uniformly charges patients before applying any contractual allowances, discounts, or deductions. |
Guarantor | The guarantor or responsible party is the person present at the facility for services. |
Guidelines | Written steps to take when following a process or procedure. |
HAC | Hospital Acquired Conditions |
HAI | Healthcare Acquired Infection |
HBV or Hepatitis B | Inflammation of the liver caused by the hepatitis B virus. Severe acute hepatitis B or chronic active hepatitis can be deadly. |
HCAHPS | Hospital Consumer Assessment of Healthcare Providers and Systems |
HCFA | Health Care Financing Administration |
HCFA 1500 | The claims form for Professional services. |
HCPCS | Healthcare Common Procedure Coding System |
HCPCS Codes | 5 digit alpha-numerical codes developed by CMS to describe items, services and procedures that do not have CPT codes assigned to those descriptions. |
HCV or Hepatitis C | The most common bloodborne infection in the U.S., which can cause serious liver disease and death. |
HDHP | High Deductible Health Plan |
Health Maintenance Organization (HMO) | Health maintenance organization (HMO): This is a prepaid health plan that provides a range of services in return for monthly premiums and meets the requirements of the federal HMO act. The four basic models of HMOs are the group model, the individual practice association, the network model, and the staff model. HMOs have three distinct characteristics: 1) an organized system for providing health care in a specific geographic area, 2) a specific set of basic and supplemental health maintenance and treatment services and 3) a voluntarily enrolled group of people. |
HEDIS | Health Effectiveness Data & Information Set |
hepat | liver |
HFMA | Healthcare Financial Management Association |
HH | Home Health |
HHA (Home Health Agency) | An agency that provides home care for patients. The care includes nursing, aides, therapies and social services. |
HHS | Health and Human Services |
HICN | Health Insurance Claim Number: The beneficiary’s policy number. |
Hierarchy | The order of importance of a group of items or services. |
HIM | Health Information Management |
HIMSS | Health Information and Management Systems Society |
HIPAA | Health Information Portability and Accountability Act |
HIV | Human Immunodeficiency Virus, the virus that causes AIDS |
HIX | Health Insurance Exchanges |
HMO | Health Maintenance Organization |
HMO Referral | The patient was admitted or referred for outpatient services upon the recommendation of an HMO physician. |
HMS | Highmark Medicare Services. Contractor of Section 1011 Program |
Hospital Lien | Legal right to settlement related to third party liability claim. Also known as a Medical lien. |
HRA | Health Reimbursement Account |
HSA | Health Savings Account |
HF | Heart Failure |
Hydration | Fluids given through a vein for the purpose of hydrating a patient. |
ICD | International Classification of Diseases |
ICD - 10 | International Classification of Diseases, 10th edition |
ICD Codes | 3-5 digit code that describes diseases, conditions and related issues. |
ICU | Intensive Care Unit |
IM | Medicare Important Message |
Indemnity | An insurance program in which members are reimbursed for covered medical expenses. This term refers to insurance plans that include little or no managed care components and simply pay a portion of medical bills incurred by the member. |
Insured | The person who holds the insurance policy. Can be the patient or another person. |
Initial | The first reported. |
Integrated Delivery System | A financial or contractual relationship between physicians and hospitals to offer a range of healthcare services through a separate legal entity. Models of these arrangements include physician-hospital organizations (PHOs), medical foundations, integrated provider organizations (IPOs), and management service organizations (MSOs). |
Internal Customer | Coworker; those that are affected by our work and actions and are commonly employed by same employer |
Intervention | An action that is performed to produce an effect that will alter the course of a disease process or improve a symptom. |
IOL | intraocular lens |
IPPS | Inpatient Prospective Payment System |
IS | itemized statement |
IV Flush | The administration of a non-medicated solution, into a patient’s vein, for the sole purpose of clearing the inserted catheter to allow it to keep a vein open. |
IV Infusion | The administration of a medication or solution, into a patient’s vein, that lasts > 16 minutes and is a continuous administration. |
IV Injection | The administration of a medication or solution, into a patient’s vein, that lasts less than 16 minutes. |
IV Start | The procedure of inserting a needle in to a patient’s vein to allow access for the injection or infusion of a solution or medication. |
IVR | Integrated Voice Recognition |
ICD9 Codes | International Classification of Diseases, Ninth Revision, Clinical Modification |
ICTF | Indigent Care Trust Fund |
Included Services | Services that the SNF or HHA is responsible for paying if they are provided by outside providers. Other providers can not bill these directly to Medicare. |
Income SSDI | Social Security Disability |
Income TANF | Temporary Assistance to Needy Families |
IP | Inpatient Services |
Judgment Liens | Court ordered lien that is placed against the home or property when the homeowner fails to pay a debt. |
KVO | Abbreviation to Keep Vein Open. The administration of a solution, at a very slow rate, for the sole purpose of keeping the vein open, so that it can be used as a portal for fluids and/or medications. |
LCD |
Local Coverage Determination |
LGHP | Large Group Health Plan |
Liability Insurance | Liability insurance is a policy that pays based on the policyholders’ alleged legal liability for illness, injury or damage to property. |
LGHP | Large Group Health Plan |
Liability Insurance | Liability insurance is a policy that pays based on the policyholders’ alleged legal liability for illness, injury or damage to property. |
LOL | Limitation of Liability |
MAC | Medicare Administrative Contractor |
MAGI | Modified Adjusted Gross Income |
MAO | Medicare Advantage Organization |
Maximum Out of Pocket | The maximum out of pocket is the amount the patient must pay for the insurance to pay all future claims at 100%. |
MBS | Modified Barium Swallow |
MCC | Major complication or co-morbidity |
MDS | Minimum Data Set OIG: Office of Inspector General |
Medicaid | Any medical assistance program administered by the state in which a hospital facility is licensed in accordance with Title XIX of the Social Security Act (42 U.S.C. 1396 through 1396w–5), including programs in which such medical assistance is provided through a contract between the state and a Medicaid managed care organization or a prepaid inpatient health plan |
Medicare fee-for-service (FFS) | Health insurance available under Medicare Part A and Part B of Title XVIII of the Social Security Act (42 U.S.C. 1395c through 1395w–5) |
Medical Necessity | The evaluation of medical services to determine if they’re: 1) medically necessary and appropriate to meet basic health needs, 2) consistent with the diagnosis, 3) rendered in a cost-effective manner and 4) consistent with national medical practice guidelines. |
Medical Payments Coverage (MedPay) | Medical payments coverage (often referred to as Med Pay) is insurance the patient can buy as part of his/her auto insurance coverage to pay for medical expenses related to an accident, whether the accident is the fault of the patient or a third party. |
Medicare Advantage or MA | A type of Medicare health plan offered by a private company that contract with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. |
Medicare Part A | Medicare Hospital Insurance |
Medicare Part B | Medicare Medical Insurance |
Medicare Part C | A combination of Part A and Part B |
Medicare Summary Notice | Notice sent to Medicare patients to make them aware of payments made to payers and/or refunds that are due. |
Medigap | Medicare supplemental policy that covers payment for deductibles and co-payments. |
MSP | Medicare Secondary Payer |
MUE | Medically Unlikely Edits |
mamm | breast |
Medical Necessity | Medicare defines “medical necessity” as being a service that is “reasonable and necessary” for the patient’s diagnosis. |
medicina | The art or science of restoring and preserving health. |
member name | person who holds the policy |
MLN | Medical Learning Network |
Mode of transmission | The way that infections are spread from one person to another. |
Modifier | A 2 digit code that is added or appended to a CPT or HCPCS code to make it more specific to the service provided. |
Modifier 50 | Bilateral |
Modifier 52 | Reduced Procedure |
Modifier 59 | Used to indicate that a procedure was performed that was completely distinct from another procedure performed on the same date of service. |
Modifier 73 | Discontinued OP Procedure (prior to anesthesia) |
Modifier 74 | Discontinued OP Procedure (after induction of anesthesia) |
Modifier 76 | Repeat Procedure |
Modifier 91 | Repeat Clinical Diagnostic Laboratory Test |
Modifier LT/RT | Identify procedures that are done on only one side of the body. |
MR | Medical Review |
MUE | Medically Unlikely Edits |
N/V | Nausea and Vomiting |
NCCI | National Correct Coding Initiative |
NCD | National Coverage Determination |
NCHS | National Center for Health Statistics |
NCQA | National Committee for Quality Assurance |
nephro | kidney |
Network | A generic term used to describe all organized groups of healthcare providers. Examples of networks include PPOs, HMOs, and IPAs. |
neuro | nerve |
No-Fault Insurance | No-Fault insurance is a form of insurance that pays for medical expenses for injuries sustained on the property or premises of the insured, or in the use, occupancy or operation of an automobile no matter who is responsible for causing the accident. |
Non-Chemotherapy | Injections or infusions of therapeutic, prophylactic and diagnostic substances. |
NOPP | Notice of Privacy Practices PHI: protected health information Prejudice Making a judgment about someone that is usually negative based on pre-conceived opinions. |
NCD | National Coverage Determination |
NCQA | National Committee for Quality Assurance |
NEMB | Notice of Exclusions from Medicare Benefits |
NF | Nursing Facility |
No-Fault Insurance | No-Fault insurance is a form of insurance that pays for medical expenses for injuries sustained on the property or premises of the insured, or in the use, occupancy or operation of an automobile no matter who is responsible for causing the accident. |
Non-diagnostic service | A therapeutic service that helps improve the patient’s condition through evaluation, therapy, or treatment |
Non-Paticipating Provider | A provider who will accept or decline assignment of Medicare benefits on a case by case basis. |
NPI | National Provider Identifier: Identifier that is now mandatory on all claims. |
NUBC | National Uniform Billing Committee |
NUCC |
National Uniform Claim Committee: Responsible for maintenance of the CMS-1500 claim form. |
Observation Care | A well defined set of specific clinically appropriate services that are furnished to a patient while a decision is being made regarding whether a patient will require further treatment as an inpatient or if they will be able to be discharged from the hospital. |
Occurrence code | A two-digit number and date used to report specific circumstances that are relevant to the claim being submitted. |
OCE | Outpatient Code Editor |
OIG | Office of Inspector General |
OMB | Office of Management and Budget |
OP | Outpatient |
OPPS | Outpatient Perspective Payment System |
OT | Occupational Therapy |
Occurrence Code | A code used for billing that gives the insurance company information about the visit. The occurrence code defines a specific event relating to the bill that may affect the processing and it also determines liability and helps coordinate benefits. |
OMB | Office of Management and Budget: Approved the CMS-1500 version 08/05. |
Open Access (OA) | This arrangement allows HMO members to see participating specialists without having to obtain a referral from their primary care physician. These are most often found in IPA-model HMOs and are also referred to as "open panel." |
Open Panel | An HMO that contracts with existing physicians and hospitals, rather than a closed panel, which is made up of salaried healthcare providers. |
OR | operating room |
Ordering Physician | A practitioner who orders non-physician services for the beneficiary. |
OSHA or Occupational Safety and Health Administration | U.S. government agency that develops and enforces standards for workplace safety and health. It is a part of the U.S. Department of Labor. |
osteo | bone |
oto | ear |
Patient | The beneficiary receiving the services |
Participating Provider | A healthcare provider who is contracted with a health plan to deliver services to covered persons. The provider may be a hospital, physician, pharmacy or other facility that has contractually accepted the terms and conditions set forth by the health plan. |
Participation | The requirement of a health plan for a certain percentage of eligible employees to participate in the employee benefit plan. For example, if a health plan has a 75% participation requirement and a group has 100 eligible employees, then 75 must enroll for coverage. Some plans also have participation requirements for eligible dependents. |
PAS | Patient Access Services |
Payer | The company, organization, or entity that pays for medical services. |
PCP | Primary Care Physician serves as a gatekeeper controlling access to more expensive care or specialty services. This physician is often charged by the managed care plan with making referrals to specialists for plan members who need access to specialty care. Managed care organization enrollees are assigned or choose a primary care physician who coordinates and manages their medical care. |
PCR Test |
Polymerase Chain Reaction Test can rapidly detect C.diff toxin B gene (tcdB) in a stool sample. |
PE | Presumptive Eligibility |
Per Diem | Per Day |
PFS | Patient Financial Services |
PHI | Protected Health Information |
phleb | vein |
PMA | Positive Mental Attitude |
POA | Present on admission. Present on Admission means present at the time the order for the inpatient admission occurs and is also used to tell not only the conditions that were known at the time of admission but also those that were present but not diagnosed until after the admission took place |
POA | Power of Attorney |
POS (Point-of-service Plan) | An HMO or PPO that includes an option allowing members to receive services outside the health plan’s provider network. These services are usually provided at a reduced benefit with much greater out-of-pocket costs and different benefit levels, and were created to offer additional flexibility in managed care plans. |
PPE | Personal Protective Equipment: Equipment that workers wear as a barrier against transmission of infectious pathogens. Includes protective gloves, gowns, masks, goggles, face shields, and resuscitation equipment. |
PPO | A group of healthcare providers that contract with an employer or other entity to provide certain healthcare services at a discounted rate. Usually, the benefit contract provides much better benefits for services received from these preferred providers. Covered persons are usually allowed benefits for non-participating providers’ services at a reduced level. Providers are usually reimbursed on a discounted fee-for-service basis. The PPO providers benefit from increased market share of patients. Many PPOs lease their networks to a variety of insurance companies in one geographic region, and they may be fully insured or offered on a self-funded basis. |
Pre-certification | The process of communicating the need for health care to the health plan prior to receiving care. This is a standard requirement for most managed care plans and is designed to help reduce unnecessary hospital admissions and medical procedures. Many plans have penalties if a member receives care without pre-certification, and some won’t pay benefits if pre-certification isn’t obtained. |
Preferred Provider | Physicians, hospitals and other healthcare providers who contract to provide healthcare services to persons covered by a particular health plan. See preferred provider organization (PPO). |
Prejudice | Making a judgment about someone that is usually negative based on pre-conceived opinions. |
Primary Insurance | The first insurance of the patient that should be billed before any other payers are billed for services. |
Prior Authorization | This is the process of obtaining prior approval by a health plan as to the appropriateness of a service or medication. This process doesn’t guarantee coverage or ensure that benefits will be paid. |
Prospective Review | The act of requesting approval before the provision of medical care. |
Provider | The hospital or healthcare facility providing treatment |
PSDA | Patient Self Determination Act |
PT | Physical Therapy |
Physician Referral | The patient was admitted to IP or referred for OP services by his or her personal physician or the patient independently requested outpatient services (self-referral). |
Principal Diagnosis | According to the Uniform Billing Editor, the condition established after study to be chiefly responsible for causing the hospitalization or use of other hospital services |
Priority Debts | Obligations the law deems to be so important that they jump to the head of the repayment line. Typical priority debts include child support, alimony, tax debts, and wages owed to employees. |
ProgramSSI | Supplemental Security |
PSC | Program Safeguard Contractors |
PT | Physical Therapy |
QA | Quality Assurance. |
RAC | Recovery Audit Contractor(s) |
Reasonable and Customary | This term refers to the most commonly charged or prevailing fees for a health plan in a specific geographic area. Most insurers pay a percentage of the "reasonable and customary" fees, while the insured individual is responsible for paying any amount charged over this "reasonable and customary" fee. |
Referral | Authorization by the health plan to send a member to another provider, including specialists and hospitals. Referral requests are made by participating health providers and approved by the primary care plan’s medical directors. |
Referring Physician | A physician who requests and item or service for the beneficiary. |
Resources | Relates to the time and effort used by staff to perform services and procedures. |
Retrospective Review | A review that occurs after medical treatment has been rendered. |
Revenue Cycle | The financial aspect of patient care from the point the patient enters your facility until the patient’s account balance is zero. |
RUG | Resource Utilization Group |
Secondary Insurance | Insurance billed after the primary has been billed |
Secure Debts | Debts backed up by some type of property. |
Self pay | Also know as Uninsured |
SMRC | Supplemental Medical Review Contractor |
SNF | Skilled Nursing Facility. Skilled section of a nursing home that provides intense care and services over and above routine nursing home care. |
SP | Self Pay |
SSI | Supplemental Security Income |
ST | Speech Therapy |
SUBC | State Uniform Billing Committee |
Swing Bed | A bed that can be used to provide either acute or skilled nursing facility (SNF) care, as needed. |
Swing Bed Program | The Swing Bed Program allows the physician to "swing" a patient’s level of care from "acute" to "skilled" rehab while the patient remains in the hospital. If the patient requires acute care again, he/she can be "swung" back to acute care. |
Sequential | Coming before or after an infusion or injection. |
Stabilize | To provide such medical treatment of the condition as may be necessary to assure withinreasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility. |
Stable for Discharge | Individual is “stable and ready” for discharge when “within reasonable clinical confidence, it is determined that the individual has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could be reasonably performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care as part of the discharge instruction.” |
SUBC | State Uniform Billing Committee |
Subscriber | The primary holder of the insurance policy. |
Tax-Exempt Hospital Organization | An organization recognized (or seeking to be recognized) as described in section 501(c)(3) that operates one or more hospital facilities. If the section 501(c)(3) status of such an organization is revoked, the organization will, for purposes of section 4959, continue to be treated as a hospital organization during the taxable year in which such revocation becomes effective. |
Team | A small number of people with complementary skills who hold themselves accountable for pursuing a common purpose, achieving performance goals and improving interdependent work processes |
TPR | Temperature, Pulse, Respirations |
Transfer | Movement (including discharge) of an individual outside a hospital’s facilities at the direction of any person employed by or affiliated with the hospital, but does not include such movement of an individual who: A. Has been declared Dead or B. Leaves the facility without the permission of any such person. |
Type A Emergency Room | An emergency room that meets all EMTALA guidelines and is open 24 hours a day 7 days a week. |
TOB | Type of Bill |
Tort Liability | This is what liability is referred to when it becomes a lawsuit. |
TPA | Third party administrator |
TPL | Third Party Liability. Third party liability refers to insurance carried by parties other than the patient, which may be liable for paying the patient’s medical expenses. |
Transfer from a Critical Access Hospital (CAH) | The patient was admitted or referred from a CAH where he or she was an inpatient |
Transfer from a Hospital | The patient was admitted to your facility from an acute care facility where he or she was inpatient or referred as an OP from the physician of another acute care facility. |
Transfer from a SNF | The patient was admitted or referred for OP services to your facility from a SNF where he or she is an inpatient. |
Transfer From Another Health Care Facility | The patient was admitted or referred from a health care facility other than an acute care facility or SNF. This includes transfers from nursing homes and long term care facilities where the patient is in a non-skilled level of care. |
Tricare | Formerly known as Champus, this is a program that covers the health benefits for families of all uniformed service employees. |
UM | Uninsured / Underinsured motorist |
Unsecured Debts | Debts for consumer goods and services. |
UPIN | Unique physician identification number |
UR | Utilization Review. |
UB04 | Universal Billing 2004 |
UB-04 | The form that medical facilities use to bill Medicare, Medicaid, Blue Cross Blue Shield, Champus/Tricare and other third party payers for the charges for services rendered to patients. |
UCR | Usual, Customary and Reasonable allowances |
UTI | Urinary Tract Infection |
VS | Vital Signs |
VA | Veterens Affairs or Veterens Administration |
VBP | Value Based Purchasing |
VHA | Veterans Health Administration |
VocRehab | Vocational Rehab Program |
Voluntary Compliance | Debtor voluntarily pays debt to creditor. |
VRS | Vocational Rehab Program |
White Paper | A document written to offer solutions to a problem |
WHO | World Health Organization |
Yearly Maximum |
This is the maximum amount of money the insurance will pay out in a year. Once the insurance has paid this maximum, the patients’ benefits will be exhausted.
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ZPIC | Zone Program Integrity Contractors |