Advanced Beneficiary Notice (ABN): A form used to inform Medicare patients that the service they are receiving will not be covered by Medicare, making sure the patient is aware that they will be responsible for payment of the service. This notice is provided prior to the service being rendered.
Account/Visit Number: A unique number that is assigned to you when you become a patient at Holland Hospital.
Amount Not Covered: The bill amount that the insurance company will not pay. It may include deductibles, coinsurances, and charges for non-covered services.
Amount Payable by Plan: The amount your insurance plan pays or covers for your treatment, less any deductibles, coinsurance, or charges for non-covered services.
Assignment of Benefits: The transfer of the right for reimbursement directly to the hospital or provider from patient’s health care provider. Transferring rights allows the insurance company to mail any payment directly to the hospital or provider. This legal statement may be signed by the patient or his/her legal spouse or guardian.
Authorization: Permission for a patient service that is granted by the health insurance plan.
Benefit: The services that are covered under your insurance plan.
Birthday Rule: This rule comes into play when a child is involved and both the father and mother have insurance coverage. The parent whose birthday comes first in the calendar year has the primary insurance coverage, regardless of the age of the parents.
COBRA Insurance: Health insurance coverage that you can purchase when you are no longer employed, or awaiting coverage from a new insurance plan to begin. Coverage may be purchased for up to 18 months from your date of separation. It is generally more expensive than insurance provided through the employer but less expensive than insurance purchased as an individual policy.
Coinsurance: The percentage of coverage not covered under your insurance benefits. For example, your policy may cover 80% of charges. Your coinsurance/patient portion would be the remaining 20%.
Co-payment/Co-pay: A set fee established by the insurance company for a specific type of visit. This amount is due from the responsible party. This information can routinely be located on the insurance card and will be different amounts according to the type of visit. For example, Emergency Room Visit - $50, Inpatient Stay - $100, Physician Office Visit - $20. Further information can be obtained by calling your insurance plan.
CPT—Current Procedural Terminology: CPT codes are universal five digit codes that are recognized by all insurance companies, hospitals and physicians. These codes are used by the insurance companies and providers to identify the type of care you receive. Insurance companies use this code, along with a diagnosis, to determine payment and reimbursement for your individual claims. The hospital and physicians use the CPT code to indicate the type of care or procedure(s) used to treat you.
Date of Service (DOS): The date(s) when you were provided healthcare services. For an inpatient stay, the dates of service will be the date of your admission through your discharge date. For outpatient services, the date of service will be the date of your visit or the date tests are performed.
Deductible: An amount that must be met on an annual basis that is established by the insurance company and your benefit plan. Call your insurance company for the most up-to-date information regarding your deductible.
DRG: DRG stands for Diagnosis Related Group. A DRG is only assigned to an inpatient hospital service. DRGs are universal groupings that are used by Medicare and most insurance companies to further clarify the type of inpatient care you receive. Insurance companies use the DRG code, along with a diagnosis code and the length of the inpatient stay, to determine payment and reimbursement for your individual claims.
Explanation of Benefits (EOB): This is a notice you receive from your insurance company after your claim for healthcare services has been processed. It explains the amounts billed, paid, denied, discounted, not covered, and the amount owed by the patient. The EOB may also communicate information needed by the insured in order to process the claim.
Financial Assistance: Hospital program that qualifies individuals for help with payment of hospital bills based on their financial need.
Guarantor: The person responsible for payment of the bill.
Guarantor Number: An identifier given to the party financially responsible for receiving and paying the monthly billing statement.
HCFA 1500: A standardized claim form developed by HCFA and used by providers (typically physicians) to bill health care carriers.
HCPCS—HCFA Common Procedural Coding System: a five-digit set of codes used to describe provider services, supplies and procedures. It includes Current Procedural Terminology (CPT) codes, but also other supplement CPTs such as those for Durable Medical Equipment (DME), ambulance services and physical therapy.
HIPAA—Health Insurance Portability and Accountability Act: Law enacted in 1996 to establish standards for handling patients’ Protected Health Information (PHI). These standards related to billing, privacy and security.
Health Maintenance Organization (HMO): An insurance plan that has contracted with providers to provide healthcare services at a discounted rate. These services will require prior pre-certification, authorization, and/or referrals.
Managed Care: An insurance plan that has a contract agreement with hospitals, physicians, and other healthcare providers.
Medicaid: A state administered federal and state-funded insurance plan for low-income families who have limited or no insurance.
Medicare: A health insurance program for people age 65 and older, some people with disabilities under age 65, and people with end-stage renal disease (ESRD). For questions concerning the Medicare program, call the Social Security Administration toll-free at 1-800-772-1213, or call your local Social Security office.
Medicare Assignment: The Medicare-approved amount of payment to Holland Hospital.
Medicare Part A (Hospital Insurance): Healthcare coverage for inpatient stays at participating hospitals.
Medicare Part B (Medical Insurance): Healthcare coverage for doctors' services, outpatient hospital care, and some other medical services that Part A does not cover, such as the services of physical and occupational therapists, and some home health care.
Medicare Summary Notice: A statement provided to patients or guardians by Medicare explaining how a claim was processed and paid.
Medigap: Medicare Supplemental Insurance available by private insurance companies that pays for some services not covered by Medicare A or B, including deductible and coinsurance amounts.
Medically Necessary Services: Covered services required to preserve and maintain the health status of a member based on established medical practical standards. These are primarily determined by your health plan.
Monthly Billing Statement: This is the Holland Hospital bill.
Network: The hospitals, clinics, health centers, doctors, medical group practices and other providers that an HMO, PPO or other managed care network has selected and contracted with to care for its members.
Non-Covered Services: Services not covered under the patient's insurance plan. These charges are the patient's responsibility to pay.
Out-of-Network Provider/Non-Participating Provider: The provider is not part of the insurance plan's network of contracted providers. Generally, services at out-of-network providers are paid for at a lower rate by the insurance plan and at a higher rate by you.
Out-of-Pocket Costs: The amount that you pay until your benefit coverage reaches 100%.
Point-of-Service Plans: An insurance plan that allows you to choose doctors and hospitals without first having to get a referral from your primary care physician.
Pre-Authorization Number: Authorization given by a health plan for a member to obtain services from a healthcare provider. This is commonly required for hospital services.
Pre-Certification Number: A number obtained from your insurance company by doctors and hospitals. This number will represent the agreement by the insurance plan that the service has been approved. This is not a guarantee of payment.
Preferred Provider Organizations (PPO): An insurance plan that has a contract with providers to provide healthcare services at a discounted rate. These services may require prior pre-certification, authorization, and/or referrals.
Preventative Care: Predetermined course of care designed to prevent disease altogether, to detect and treat it early, or to manage its course most effectively. Examples of preventative care include immunizations and regular screenings like Pap smears or cholesterol checks.
Primary Care Physician (PCP): The primary care physician (can be an internist, pediatrician, family physician, or OB/Gyn) is responsible for all general medical care of the patients and referrals to specialists for care when medically appropriate. Most HMO, EPO and POS plans require members to choose or be assigned to a primary care physician. The PCP is responsible for providing or authorizing all care (hospitalization, diagnostic, workups and specialty referrals) for that patient. Depending on the type of insurance plan, a patient may not be covered for a visit to a specialist without prior approval of the primary care provider.
PHI—Protected Health Information: Any information that can identify you as an individual and your past, present or future physical or mental health condition.
Primary Insurance Company: The insurance company primarily responsible for the payment of the claim.
Protected Health Information (PHI): Any information that can identify you as an individual and your past, present or future physical or mental health condition.
Referral: Approval or consent by a primary care doctor for a patient to see a certain specialist or receive certain services.
Secondary Insurance: The insurance company responsible for the remainder of the claim after the primary insurance has determined benefits. If a patient has dual coverage, Holland Hospital will file a claim for service with the secondary insurance.
Self-Payment or Self-Pay: If you do not have insurance, or if you are seeking care at Holland Hospital outside of your insurance plan benefits, you are considered a self-pay patient.
Share of Cost (SOC): The amount a beneficiary must pay toward their health care costs before insurance will pay. The SOC may change when monthly income changes.
Specialist: A doctor or other health care professional whose training and expertise is in a specific area of medicine, such as cardiology or orthopedics. Most HMOs require members to get a referral from their primary care physician (PCP) before seeing a specialist.
Subscriber: The person responsible for payment of premiums or whose employment is the basis for eligibility for a health plan membership.
Supplemental Insurance: Insurance available by private insurance companies that pays for some services not covered by Medicare A or B, including deductible and coinsurance amounts.
Third Party Liability (TPL): Liability Insurance coverage becomes your primary insurance when an accident is the reason for your visit to Mission Hospital. Patient accounting will make every effort to identify and coordinate coverage so your account is paid in a timely manner.
UB 04: A hospital billing form used to submit an itemized invoice of medical services and corresponding charges. This is a Uniform Billing Code of 2004, a revised version of the UB92, a federal directive requiring a hospital to follow specific billing procedures.
Urgent Care Center: A health care facility that provides immediate but non-emergent care for a minor illness or injury, allowing ambulatory walk-in service on an extended-hour or 24-hour basis.
Worker’s Compensation: Worker Compensation provides insurance-type coverage for work-related illnesses and accidents. In order to use this insurance you must provide the appropriate insurance information, employer information, claim number and date of injury. This coverage is separate from regular medical coverage.