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.
ZPIC	Zone Program Integrity Contractors

Glossary

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