Medical Billing List of Terms 

Medical Billing Glossary

A TIER - specific list of drugs. The co-payment amount depends on which tier the drug is listed under. Plans can choose their own tier.

ABUSE - when another person does something purposely to cause you mental or physical harm or pain.

ACCESS - The ability to get medical care and services.

ADL (Activities of Daily Living)- activities that are done during a normal day such as getting in and out of bed, bathing, etc.

ACTUAL CHARGE - the amount a doctor or supplier charges for a certain service or supply.

AAPCC (Adjusted Average Per Capita Cost) - Estimate of how much Medicare will spend per year for an average beneficiary.

ADVOCATE - A person who protects your rights and gives you support.

AUTHORIZATION - MCO approval necessary prior to the receipt of care.

BASIC BENEFIT - includes both Medicare - covered benefits and additional benefits.

BENEFICIARY - The name of person who has health care insurance through the Medicare - Medicaid Program.

BENEFITS - The money or services provided by an insurance policy.

CAPITATION - The specific amount paid to a health plan or doctor.

CARRIER - A private company that has a contract with Medicare to pay your Medicare part B bills.

CLAIM - A request of payment of services and benefits you received.

CONDITIONAL PAYMENT - A payment made by Medicare for services for which another payer is responsible.

DEDUCTIBLE - the amount you must pay for health care before Medicare begins to pay.

DIAGNOSIS - The name of the health problem that one has.

DISCOUNT DRUG LIST - A list of certain drugs and their proper doses. This list includes the drugs a company will discount.

DISENROLL - Ending your health care coverage with a health plan.

DURABLE POWER OF ATTORNEY - A legal document that allows you to designate another person to act in your behalf, in the event you become disabled or incapacitated.

ELECTION - The decision to join or leave the Original Medicare Plan or Medicare+Choice Plan.

EXCLUSIONS - Items that Medicare does not cover.

FEE SCHEDULE - A complete list of fees used by health care plans to pay doctors and other providers.

FISCAL INTERMEDIARY - A private company that has a contract with Medicare to pay Part A and some Part B bills.

FORMULARY - A list of certain drugs and their proper doses. In some Medicare plans, doctors must order and use only drugs listed on the health plan’s formulary.

GAPS - The cost or services not covered on the Original Medicare Plan.

GEP (General Enrollment Period) - The GEP is January 1st through March 31st of each year. When someone enrolls in Part A or B Medicare during the GEP, your coverage begins on July 1st.

GRIEVANCE - A complaint about the way Medicare gives health care.

HIPAA - Health Insurance Portability & Accountability Act protects individuals and families if they have pre-existing medical conditions, and/or problems getting health coverage and think it is based on past or present health. This law expands health care coverage if someone has lost their job, or if they move from one job to another. HIPAA also limits how companies can use their pre-existing medical conditions to keep from getting health insurance coverage. HIPAA does not replace the states roles as primary regulators of insurance.

HEALTH MAINTENANCE ORGANIZATIONS (HMO) - A type of Medicare managed care plan where a group of doctors, hospitals, and health care providers agree to give health care to Medicare patients for a set amount of money from Medicare monthly.

HOSPICE - Covered under Medicare Part A, Hospice provides care for a patient and their families for the terminally ill.

INITIAL COVERAGE ELECTION PERIOD - The three months immediately before one is entitled to Medicare part A and enrolled in Medicare part B.

INITIAL ENROLLMENT PERIOD - This period is the first chance one has to enroll in Medicare part B. It starts three months before one first meets all eligibility requirements for Medicare and lasts seven months.

INTERMEDIARY - A private company that has a contract with Medicare to pay Part A and some Part B bills.

LIFETIME RESERVE DAYS - In the original Medicare Plan, Sixty days that Medicare will pay for when you are in a hospital more than ninety days during a benefit period. This reserve can be used only once during your lifetime.

MANAGED CARE PLAN - You can only go to doctors, specialists, or hospitals on this plan. Plans must cover all Medicare Part A and Part B health care.

MEDICAID - A joint Federal and State program that helps with medical costs for some people with low incomes and limited resources.

MEDICAL INSURANCE PART B - Medicare medical insurance that helps to pay for doctor services, out-patient hospital services, durable medical equipment, and some medical services that are not covered by Medicare Part A.

MEDICARE - Federal health care program for people sixty five years old and older, younger people with disabilities and for people with ESRD otherwise known as End Stage Renal Disease (kidney failure).

MEDICARE BENEFITS NOTICE - people will receive a notice after a doctor files a claim for Medicare Part A services. It will state what the provider billed for, the Medicare Approved amount, how much Medicare paid, and how much of the bill one is responsible for.

MEDICARE CARRIER - A private insurance company that contracts with Medicare to cover Part B bills.

MEDICARE COVERAGE - Medicare Part A, hospital insurance and Medicare Part B, medical insurance.

MEDICARE PART A - Medical insurance that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care.

MEDICARE PART B - medical insurance that helps pay for doctors, outpatient hospital care, durable medical equipment and some medical services that aren’t covered by Medicare Part A.

MPCC (MEDICARE PREMIUM COLLECTION CENTER) - The contractor that handles all Medicare direct billing payments for direct billed beneficiaries.

OUT OF POCKET COSTS - Health care expenses that one must pay on your own because they are not covered by Medicare or the health care provider.

OUTPATIENT PROSPECTIVE PAYMENT SYSTEM - The way that Medicare pays for outpatient services under Medicare Part B.

PAYMENT RATE - Total payment that the hospital community mental health center receives when they give outpatient services to Medicare recipients.

PERFORMANCE MEASURE - Information that shows how well a health care plan provides services to its members.

PRE-EXISTING CONDITION - A health condition that occurred before the date that a new health plan starts.

PREMIUM SURCHARGE - The standard Medicare Part B premium will go up 10% for each twelve month period that one could have had Medicare Part B but chose not to take it.

PRIMARY PAYER - An insurance plan, policy, or program such as Medicare that pays first on a claim for medical care.

PROCEDURE - Something done to fix or learn more about a health problem.

QMB (QUALIFIED MEDICARE BENEFICIARY) - Medicaid program for people who need help in paying Medicare services. The person must have Medicare Part A and limited income and resources. If one qualifies, Medicaid programs will pay Medicare Part A premiums, Part B premiums, and Medicare deductibles and co-insurance amounts for Medicare services.

REFERRAL - A written document from a primary doctor to see a specialist. With many Medicare Managed Care Plans, one must have a Referral before they can get care from anyone but their primary doctor.

RISK ADJUSTMENT - The way a health plan are changed to take in account the persons health status.

SECONDARY PAYER - Insurance policy, plan or program that will pay second on a claim for medical care. This could be Medicare or Medicaid.

SERVICE CATEGORY DEFINITION - Description of the types of services provided and the characteristics that define the service.

WAITING PERIOD - Time between when you sign up with a Medicare health plan and when the coverage starts.