Billing and Insurance Glossary

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Account

This number is used to identify each stage of care. This number is used to track services and payments.

Recipient

The recipient is the person designated to receive the monthly statement. This person is responsible for coordinating billing, payments, and insurance coverage for the account.

Beneficiary Advance Notice (ABN)

This is written notice from a doctor, medical provider, or supplier to you before providing any services that may not be covered by Medicare. An ABN (Advance Beneficiary Notice), also known as a Release of Liability, is issued by a health care provider when they provide services or items that they believe are not covered by Medicare. ABNs apply only if you have traditional Medicare, not if you are enrolled in a Medicare-advantaged private health plan.

Premium Limit

This refers to a predetermined premium limit by which an insurance company limits the maximum amount they will pay for a service based on their contract with you. Please be aware that for health plans that are not participating in the United States, United States Medical International does not accept the scheduled Regular, Customary, and Reasonable (UCR) health insurance payment amounts. “Premium Limit” charges are sometimes referred to as Reasonable and Customary (R&C) charges.

Premium amount

The maximum amount paid for covered medical services. This may be called a “qualified fee”, “payment allowance” or “negotiated fee”. If your healthcare provider charges more than the premium amount, you may have to pay the difference. See “Balance Bill”.

Outpatient medical

Outpatient care is medical care that is performed in a doctor’s office or surgical center without requiring an overnight hospital stay.

Appeal

A request to your health insurance company or plan to review a decision or complaint.

Authorize

Authorization is the approval of care, such as hospitalization, by an insurance company or health plan. Your insurance company or health plan may require pre-authorization before you receive treatment.

Balance

The amount is owed to Miaoyou Medical International is stated on the bill.

Balance bill

Balance billing is the practice of a healthcare provider charging you for charges not covered by an insurance plan, even if those charges exceed the plan’s usual, customary and reasonable (UCR) charges or are deemed medically unnecessary. Managed-care plans and service plans generally prohibit providers from billing balances unless the associated costs are allowable copays, coinsurance, and deductibles. This prohibition of billing balances may even extend to situations where the plan cannot pay at all (for example, due to bankruptcy).

Billing account

This is the account number of the bill recipient (guarantor) designated to receive the bill. Please include this number when contacting MyoHealth International with questions.

Bill recipient (guarantor)

The recipient is the person designated to receive the monthly statement. This person is responsible for coordinating billing, payments, and insurance coverage for the account.

Certification

Certification is an official authorization to use the service.

Claim Review

A claims review is a review that an insurance company or health plan does before it pays the doctor or reimburses you. This review is used by insurance companies to verify the medical suitability of services provided and to review the costs associated with your care.

Co-insurance

Coinsurance is a provision that limits an insurance company’s coverage to a certain percentage (usually 80%). This provision is common in indemnity insurance plans and preferred provider plans. If your insurance includes coinsurance, you will be responsible for charges beyond coverage.

commercial health insurance

This is non-government insurance that covers all or part of your medical bills. This insurance can be purchased by an individual or an employer and is usually obtained as an employment benefit.

Coordination of Benefits (COB)

Benefit coordination is an agreement between your insurance companies to prevent different insurance companies from paying for your care twice when your care is covered by more than one plan. The agreement determines which insurance company is primarily responsible for payments and which is secondary.

Copay

A copay is a portion of a claim or medical bill that you must pay out of pocket. Copays are usually fixed amounts.

Cost-sharing

Your out-of-pocket share of covered costs. Cost-sharing usually includes deductibles, coinsurance, co-payments, or similar charges. Does not include premiums, non-in-network provider balance bill amounts, or charges for non-covered services.

Covered Expenses

Refers to the charges for services normally covered under the terms of a contract with an insurance company. It’s important to keep in mind that even though services may be covered, reimbursement for these services is generally still subject to the deductible and coinsurance out-of-pocket portion.

Credit balance

This balance may appear on the statement under “Current Amount due” with a negative sign after the relevant amount (for example, $100-). This is the amount that Miracle Medical International should refund to the patient or insurance plan after reviewing the account.

Current Medical Procedure Terminology (CPT) Code

Medical personnel use this set of five-digit codes to bill and authorize services.

deductible

The deductible is the portion of your health care costs that you must pay before your insurance applies.

refusal to claim reimbursement

Your health care plan has determined that your benefit plan specifies services that are not covered by benefits, or that there are certain restrictions on when services can use benefits. If your insurance denies reimbursement for a service, you will be responsible for paying the full amount.

Diagnostic Relevant Group (DRG)

DSG is a system for classifying hospital costs. The Centers for Medicare and Medicaid Services uses DSGs to derive standard reimbursement rates for medical procedures and to pay medical bills for Medicaid recipients. Some states use DSG for all payers, while some private health plans use DSG for contracting.

Optional service

Any non-emergency care services. With few exceptions, cosmetic surgery is an elective service that must be prepaid by the patient.

Explanation of Benefit (EOB)

A benefit statement is a statement mailed to the insured explaining how a claim is paid or why the service is not covered. Medicare beneficiaries receive a Medicare Summary Notice (MSN).

Fee Schedule

The Fee Schedule is a list of the highest fees a health plan pays for each service based on the CPT billing code. Some plans refer to this as the Maximum Fee or Fee Subsidy Schedule.

HCFA 1500 form

The HCFA 1500 form is required by Medicare and Medicaid and is used by some private insurers and managed care plans for billing purposes. HCFA 1500 is the official standard form used by physicians and other healthcare providers to submit bills and claims, request reimbursement to Medicare, Medicaid, and private insurers, and includes patient demographic information, diagnosis codes, CPT / HCPCS codes, diagnostic codes, and units.

Health Maintenance Organization (HMO)

There are several definitions of HMO: 1. An organization that provides health care to members after charging them a predetermined amount. 2. A health plan that puts at least some providers at risk of medical bills. 3. A health plan that uses a primary care physician to determine whether a member needs care from a specialist (but some HMOs do not).

Hospice

Hospice is a facility or program that provides care for terminally ill people. Hospice care involves a team-oriented approach that addresses a patient’s medical, physical, social, emotional, and spiritual needs. Hospice care is covered under Medicare Part A (hospital coverage).

In-Network Providers

Providers who contract with a health insurance company or plan to provide services for you. Also known as Preferred Provider.

International Classification of Diseases (ICD) codes

The ICD code is the International Classification of Diseases used for diagnosis and treatment.

Detail statement

A detailed list of all services provided to patients. Expense detail statements include diagnostic codes and CPTs used when submitting claims to insurance plans. Detail statements are not bills.

Managed Healthcare

Managed health care refers to a health care delivery system that manages the cost and quality of health care and access to care. It typically involves using a contracted provider network, limiting medical benefits from non-contracting providers (unless authorized), and using a medical authorization system. Managed care includes managed indemnity plans, preferred provider organizations, point-of-care plans, open HMOs, and closed HMOs.

Miaou Medical International Signing Service

Miaou Medical International contracts with specific insurance companies and provides these medical services to patients by contractual amounts.

Miaou Medical International Number

This is your PIN at Miaoyou Medical International. It is a unique number that can be used for your lifetime at MyoHealth International.

Medicaid

Medicaid is a federally and state-funded program that provides health care coverage and nursing home care to low-income people. Benefits vary widely from state to state.

Medicaid (Title XIX)

It’s a joint federal-state program to help some people with lower incomes and limited resources pay for their health care. States have their standards for eligibility, insurance benefits, program eligibility, provider payment rates, and methods for administering programs.

Medicare

Medicare is a federal program designed to provide coverage for seniors 65 and older and people with disabilities of all ages. Medicare Part A covers hospitalization and is a mandatory benefit. Medicare Part B covers outpatient services and is a voluntary benefit.

Medicare (Title XVIII)

This federal program is for: Age 65 and older, eligible for two or more years of Social Security benefits, and certain workers and their families (regardless of financial status) who need kidney transplants or dialysis. The program consists of two separate but coordinated programs: hospital insurance (Part A) and supplemental health insurance (Part B), and a separate drug insurance program (Part D) administered by the private sector.

Medicare Advantage Program

Medicare Advantage is a plan offered by private companies that contract with Medicare to provide Medicare Part A and Part B benefits. Medicare Advantage plans can be HMOs, PPOs, or private fee-for-service plans. When enrolled in the Medicare Advantage plan, the plan will cover the policyholder’s Medicare services. Traditional Medicare coverage does not cover these services.

Medicare Advantage Program (Medicare Part C)

Medicare Part C is a Medicare health plan offered by private companies that contract with Medicare to provide you with all the benefits of Parts A and B.

Medicare Distribution Limits

An allocation limit is when your doctor, provider, or provider agrees to accept Medicare-approved amounts as full payment for covered services. Most doctors and health care providers accept allocation limits, but you should always check. Medicare’s Arizona, Florida, and Minnesota campuses accept Medicare distribution limits.

Medicare Non distribution Limit

Providers who do not accept distribution limits are called non-participating providers who do not sign the Agreement Form for Accepting Distribution Limits for all Medicare-covered services. Most doctors and health care providers accept allocation limits, but you should always check.

Miracle Medical International will file a claim with Medicare, charging up to 15% more than the Medicare-approved amount. If you have a Medicare Supplement policy, coverage may or may not include the 15% “over Medicare” cost.

Call Patient Account Services toll-free at 844-217-9591 Monday through Friday to make bill payments or ask questions about your statement.

  • Arizona, 8:00 a.m. to 5:00 p.m. Mountain Time
  • Florida, 8:00 am to 5:00 pm ET
  • Minnesota, 8:00 AM to 5:00 PM Central Time

Medicare automatic deficit reduction

Effective April 1, 2013, Medicare will reduce payments by 2% for Medicare claims with service or discharge dates on or after April 1, 2013. This claim payment adjustment shall be applied to all claims after determining coinsurance amounts, any applicable deductibles, and any applicable Medicare secondary payment adjustments. While deductible and coinsurance beneficiary payments are not affected by the 2% payment deduction, Medicare payments to beneficiaries will be withheld 2% for unprocessed claims. If you have questions about reimbursement, please contact your Medicare claims management contractor directly.

Medicare Summary Notice

This is the instruction Medicare provides to Medicare attendees explaining how it processes and pays claims.

Medicare Difference Insurance

Medicare gap insurance is private insurance that supplements Medicare reimbursement for medical services. Medicare reimbursements for medical expenses are generally lower than what doctors charge. Medicare gap coverage is designed to make up the difference between what Medicare is reimbursed for and what the provider charges so that Medicare recipients don’t have to pay the difference.

Non-covered expenses

It depends on your policy. Non-covered charges are charges for services not covered by the terms of your insurance plan. If your insurance does not cover a service, you will be responsible for the full amount of the service.

Uncovered Services

Services not covered by the patient’s health insurance contract. The amount for these services will be paid by the patient. For questions about coverage, patients should consult their health plan directly.

Not involved

Providers who choose not to accept Medicare-approved amounts as full payment.

Out of network

Providers who are not contracted with your health insurance company or plan. Additional charges apply if you receive services from out-of-network or non-preferred providers. Check your policy to see if you can get services from all the providers your health insurance or plan contracts with, or if your health insurance or plan has a “tiered” network, and if you get services from certain providers service, an additional fee must be paid.

Daily sales

In daily reimbursement, institutions such as hospitals receive a flat fee each day instead of being reimbursed for the cost of each service provided. Daily reimbursements may vary by service (eg, medical or surgical, obstetrics, mental health, and critical care) or maybe a flat fee.

Point of Service (POS) Program

Point-of-care plans are plans in which members choose service coverage only when they need medical care. Typically, the program will enroll all members into an HMO (or HMO- like) system and compensation plan. These plans offer different benefits depending on whether members are in the plan or not. Double opt-in refers to an HMO -like plan an indemnity plan, while triple opt-in refers to adding a PPO to that double opt-in.

Pre-admission clearance

Pre-admission clearance is also known as pre-admission review or pre-authorization. Pre-admission clearance is the practice of reviewing an application for admission before you are admitted to the hospital.

Deposit before treatment

Where applicable, Miracle Medical International will pre-determine the amount to be paid before your visit.

Pre-authorization

Pre-authorization, also known as pre-admission authorization or pre-admission review, is the process of obtaining authorization for routine admissions (inpatient or outpatient) from an insurance plan. Failure to obtain pre-authorization often results in reduced reimbursement or denied claims.

Preferred Provider Organization (PPO)

Preferred provider organizations contract independent providers for services. Physicians in a PPO are charged according to the fee schedule for services, and their charges are lower than standard rates after discounts. The list of such providers is limited, and PPOs typically review healthcare use. PPO members can sometimes use doctors outside the PPO network, but usually have to pay more.

Primary Care Physician (PCP)

Primary care doctors are sometimes called “gatekeepers,” and are usually the first doctor you see when you get sick. They will treat you directly, refer you to a specialist (secondary care) or arrange for you to be hospitalized. Your PCP may be a family doctor, an internist, a pediatrician, or sometimes an obstetrician.

Major insurance companies

This is the insurance company that has the first responsibility for the payment of claims.

Prior authorization or prior written approval

Before you can get a service or get a prescription filled, you need approval from your health plan to cover the service or drug.

healthcare provider

A healthcare provider is any provider of healthcare services such as a doctor, pharmacist, physical therapist, etc.

Proof of Health Insurance

A valid insurance card that includes the address to submit the claim.

Reasonable and Customary (R&C)

Reasonable and customary is the predetermined limit that the insurance company applies under the contract with you to limit the maximum amount that will be paid for the service. Please note that MyoHealth International does not accept scheduled health insurance payments from non-participating health plans. R&C is also known as the licensed amount or UCR.

 

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