In this chapter, we learn to remain part of abbreviation alphabet N to W. After this chapter we will cover other parts of USA healthcare and Medical Billing/coding.
Non-Covered Charge (N/C): N/Cs are procedures and services not covered by a person’s health insurance plan.
Not Elsewhere Classifiable (NEC): A term used to describe a procedure or service that can’t be described within the available code set.
Network Provider: A provider within a health insurance company’s network that has contracted with the company to provide discounted services to a patient covered under the company’s plan.
Non-participation: This is when a provider refuses to accept Medicare payments as a sufficient amount of the services rendered to a patient.
National Provider Identifier (NPI) Number: A unique 10-digit number provided to every healthcare provider in the U.S. as mandated by HIPAA.
Office of Inspector General (OIG): The organization responsible for establishing guidelines and investigating fraud and misinformation within the healthcare industry. The OIG is part of the Department of Health and Human Services.
Out-of-Network: Out-of-network refers to providers outside of an established network of providers who contract with an insurance company to offer patients healthcare at a discounted rate. People who go to out-of-network providers typically have to pay more money to receive care.
Outpatient: This term refers to healthcare treatment that doesn’t require an overnight hospital stay, including a routine visit to a primary care doctor or a non-invasive surgery.
Patient Responsibility: This refers to the amount a patient owes a provider after an insurance company pays for their portion of the medical expenses.
Primary Care Physician (PCP): The physician who provides the basic healthcare services for a patient and recommends additional care for more serious treatments as necessary.
Point of Service Plans: A plan whereby patients with HMO membership may receive care at non-HMO providers in exchange for a referral and paying a higher deductible.
Place of Service Code: A two-digit code used on claims to explain what type of provider-performed healthcare services on a patient.
Preferred Provider Organization (PPO): A plan similar to an HMO whereby a patient can receive health care from providers within an established network set up by an insurance company.
Practice Management Software: Software used for scheduling, billing, and recordkeeping at a provider’s office.
Preauthorization: Some insurance plans require that a patient receive preauthorization from the insurance company prior to receiving certain medical services to make sure the company will cover expenses associated with those services.
Pre-Certification: A process similar to preauthorization whereby patients must check with insurance companies to see if the desired healthcare treatment or service is deemed medically necessary (and thus covered) by the company.
Pre-determination: A maximum sum as explained in a healthcare plan an insurance company will pay for certain services or treatments.
Pre-existing Condition (PEC): PEC is a medical condition a patient had before receiving coverage from an insurance company. A person might become ineligible for certain healthcare plans depending on the severity and length of their PEC.
Pre-existing Condition Exclusion: The existence of a PEC denies a person certain coverage in some health insurance plans.
Premium: The sum a person pays to an insurance company on a regular (usually monthly or yearly) basis to receive health insurance.
Privacy Rule: Standards for privacy regarding a patient’s medical history and all related events, treatments, and data as outlined by HIPAA.
Provider: A provider is the healthcare facility that administered healthcare to an individual. Physicians, clinics, and hospitals are all considered providers.
Provider Transaction Access Number (PTAN): This refers to a provider’s current legacy provider number with Medicare.
Referral: This is when a provider recommends another provider to a patient to receive specialized treatment.
Remittance Advice (R/A): The R/A is also known as the EOB, which is the document attached to a processed claim that explains the information regarding coverage and payments on a claim.
Responsible Party: The person who pays for a patient’s medical expenses, also known as the guarantor.
Revenue Code: A three-digit code used on medical bills that explains the kind of facility in which a patient received treatment.
Relative Value Amount (RVA): The median amount Medicare will repay a provider for certain services and treatments.
Scrubbing: A process by which insurance claims are checked for errors before being sent to an insurance company for final processing. Providers scrub claims in an attempt to reduce the number of denied or rejected claims.
Self-Referral: When a patient does their own research to find a provider and acts outside of their primary care physician’s referral.
Self-Pay: Payment made by the patient for healthcare at the time they receive it at a provider’s facilities.
Secondary Insurance Claim: The claim filed with the secondary insurance company after the primary insurance company pays for their portion of healthcare costs.
Secondary Procedure: This is when provider performs another procedure on a patient covered by a CPT code after first performing a different CPT procedure on them.
Security Standard: The security standard serves as the guidelines for policies and practices necessary to reduce security risks within the healthcare system. The security standard policies work in concert with the security guidelines set in place with the passage of HIPAA.
Skilled Nursing Facility: These are facilities for the severely ill or elderly that provide specialized long-term care for recovering patients. Skilled nursing facilities are alternative healthcare establishments to extended hospital stays and may be covered by eligible patients’ insurance policies.
Specialist: A physician or medical assistant with expertise in a specific area of medicine. Oncologists, pediatricians, and neurologists are among the many specialists in the medical field.
Subscriber: The subscriber is the individual covered under a group policy. For instance, an employee of a company with a group health policy would be one of many subscribers on that policy.
Superbill: A document used by healthcare staff and physicians to write down information about a patient receiving care. The superbill can contain demographic information, insurance information, and especially any diagnoses or healthcare plans written by the physician. A medical billing specialist inputs the information on a patient’s superbill into a claim.
Supplemental Insurance: Supplemental insurance can be a secondary policy or another insurance company that covers a patient’s healthcare costs after receiving coverage from their primary insurance. Supplemental insurance policies typically help patients cover expensive deductibles and copays.
Treatment Authorization Request (TAR): A unique number the insurance company gives the provider for billing purposes. A provider must receive the insurance company’s TAR number before administering healthcare to a patient covered by the company.
Taxonomy Code: Medical billing specialists utilize this unique codeset for identifying a healthcare provider’s specialty field.
Term Date: The end date for an insurance policy contract, or the date after which a person no longer receives or is no longer eligible for health insurance with company. Term dates are typically determined on a case-by-case basis.
Tertiary Insurance Claim: A claim filed by a provider after they have filed claims for primary and secondary health insurance coverage on behalf of a patient. Tertiary insurance claims often cover the remaining healthcare costs such as deductibles and co-pays left over after the primary and secondary claims have been processed.
Third Party Administrator (TPA): The name for the organization or individual that manages healthcare group benefits, claims, and administrative duties on behalf of a group plan or a company with a group plan.
Tax Identification Number (TIN): A unique number a patient or a company may have to produce for billing purposes in order to receive healthcare from a provider. The TIN is also known as the employment identification number (EIN).
Triple Option Plan (TOP): Also referred to as the cafeteria plan, this plan gives an enrolled individual the options to choose between an HMO, a PPO, or a traditional point of service plan for their health insurance. Some companies offer triple option plans to their employees to accommodate the needs of a diverse staff.
Type of Service (TOS): A field on a claim for describing what kind of healthcare services or procedures a provider administered.
TRICARE: TRICARE is the federal health insurance plan for active service members, retired service members, and their families, in addition to survivors of service members. TRICARE was previously known as CHAMPUS.
UB04: A form used by providers for filing claims with insurance companies. The UB04 form has a format similar to that of the CMS 1500 form.
Unbundling: This term refers to the fraudulent practice of ascribing more than one code to a service or procedure on a superbill or claim form when only one is necessary.
Untimely Submission: Claims have a specific timeframe in which they can be sent off to an insurance company for processing. If a provider fails to file a claim with an insurance company in that timeframe, it is marked for untimely submission and will be denied by the company.
Upcoding: Upcoding is the fraudulent practice of ascribing a higher ICD-9 code to a healthcare procedure in an attempt to get more money than necessary from the insurance company or patient.
Unique Physician Identification Number (UPIN): A unique six-digit identification number given to physicians and other healthcare personnel, which has subsequently been replaced by a national provider identifier (NPI) number.
Usual Customary and Reasonable (UCR): The UCR is the amount of money stipulated in a contract that an insurance company agrees to pay for healthcare costs. After passing the UCR a patient is typically responsible for covering their healthcare costs.
Utilization Limit: The limit per year for coverage under certain available healthcare services for Medicare enrollees. Once a patient passes the utilization limit for a service, Medicare may no longer cover them.
Utilization Review (UR): An investigation or audit performed to optimize the number of inpatient and outpatient services a provider performs.
V-Codes: A codeset under ICD-9-CM used to organize healthcare services rendered for reasons other than illness or injury.
Worker’s Compensation: Worker’s compensation is paid by an employer when an employee becomes ill or injured while performing routine job duties. Most states have laws requiring that companies provide worker’s compensation.
Write-Off: This term refers to the discrepancy between a provider’s fee for healthcare services and the amount that an insurance company is willing to pay for those services that a patient is not responsible for. The write-off amount may be categorized as “not covered” amounts for billing purposes.