A Glossary of Medical Billing Terms
If you are interested in pursuing career opportunities in medical billing and coding, you should learn how to talk like someone in the medical billing field.
Here is a small glossary of medical billing terms to get you started:
- Aging – Unpaid insurance claims or patient balances that are 30 days or more past due.
- Beneficiary – Person(s) covered by the health insurance plan.
- Crossover claim - When claim information is automatically sent from Medicare to the secondary insurance (e.g. Medicaid).
- HIPAA (Health Insurance Portability and Accountability Act) - Federal regulations intended to improve the efficiency and effectiveness of health care and establish privacy and security laws for medical records. In fact, some new medical billing terms have been introduced by HIPAA.
- Maximum Out of Pocket - The maximum amount the insured is responsible for paying (refers to eligible health plan expenses only). When this maximum is reached, insurance will then typically pays 100% of eligible expenses. This does not have to be for one medical occurrence but includes medical occurrences over the course of a year.
- Medical Necessity – A medical service or procedure provided for treatment of an illness or injury and is not considered investigational, cosmetic or experimental.
- Predetermination – The maximum amount that insurance will pay towards surgery, consultation, or other medical care. The amount is determined prior to treatment.
- SAAS (Software As A Service) - A software application, like medical billing, that is hosted on a server and accessible over the Internet. With SAAS, the user does not need software maintenance and support. In addition, the software is ready to go without the need to install and run an application on a PC or server.
- UCR (Usual Customary & Reasonable) – The maximum amount that a patient’s insurance company will pay for a given service or medical item as defined in the contract with the patient.
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