The electronic UB-04
AAPC American Academy of Professional Coders


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. 


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.


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.




Activities of Daily Living
ADR Additional Documentation Request


Adjusted Gross Income

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.


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).


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.


Agency for Healthcare Research and Quality


Acknowledge, Introduce, Duration, Explanation, Thank You


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.


American Medical Association


Acute Myocardial Infarction


Ambulatory Payment Classification


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


Prefix meaning or relating to the joint


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).


Blood Alcohol Test
BCBS Blue Cross Blue Shield


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


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.


Consolidated Billing


Complication or co-morbidity


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.


Comprehensive Error Rate Testing


Chief Financial Officer HIS: Health Information System
CHNA Abbreviation for Commuity Health Needs Assessment


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.

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.

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


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
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
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