Glossary of medical office terms
Allowable Fee, or Usual and Customary Reimbursement (UCR): The maximum amount a health insurer will pay for a service or procedure. At Highlands Pediatrics PC and Internal Medicine Associates PC patients who have to cover their own medical costs get a discount from a typical fee structure, which is equivalent to an uninsured patient paying Medicare fees
Balance Billing: A billing practice in which you are billed for the difference between what your insurer pays and the fee that the provider normally charges. At Highlands Pediatrics PC and Internal Medicine Associates PC we do not balance bill.
Coinsurance: Some insurance coverage requires you to pay a percentage of the cost of covered medical services, usually 20-30 percent. For example, you pay 20 percent of the cost, and your insurance pays 80 percent of the cost. Your portion of the cost is the coinsurance. Coinsurance are due on the day of service at Highlands Pediatrics PC and Internal Medicine Associates PC.
Commercial Insurers: Corporations which provide health insurance rather than the state or federal government
Copayment: A flat fee for specified medical services required by some insurers. For example, you pay a $20 copayment for a doctor visit or a $100 copayment for a hospital stay.
Deductible: The amount you must pay each year for your medical expenses before your insurance policy starts paying. Deductibles are common in fee-for-service coverage.
Fee-for-Service (FFS): Also known as indemnity insurance, FFS is a type of health coverage that typically allows you to go to any doctor or provider. Your insurance company will reimburse your provider for each covered service provided. Deductibles and coinsurance usually apply in FFS coverage.
HIPPA Health information proscenium portability act. This is the statute each that determines how medical records once per juiced in a medical treatment environment are handled and protected.
Out-of-pocket maximum: The amount of co-insurance a member must pay before out-of-network claims will be paid at 100% of the allowed amount. The amount will depend on your plan
Participating Provider: A health care provider (e.g., doctor, psychologist, hospital) who agrees to accept the terms, conditions and allowable payments of an insurer. Highlands Pediatrics PC and Internal Medicine Associates PC participate in most plans except for Tenn-Care which we are not allowed to participate in. If your insurance cup he tells you that we are not participating provider. Please contact us immediately. In most cases, we find, this is due to an error on the part of the insurance company.
Point of Service (POS) Plan: A type of managed care coverage that allows members to choose to receive services either from participating HMO providers or from providers outside the HMO’s network. Members pay less for in-network care. For out-of-network care, members usually pay a deductible and coinsurance.
Premium: The fee paid to your insurance company or federal or state government to cover the cost of your healthcare.
Primary Care Physician (PCP): An internist, pediatrician, family physician, general practitioner, or in some instances an obstetrician/gynecologist. The PCP coordinates your care and makes referrals to specialists as needed. Most Medicaid patients are required to choose a PCP. It is important if Medicaid contacts you about your PCP to respond immediately or else they will arbitrarily you assign you to a primary care physician. It may take up to a year to correct that mistake.
Referral: Authorization from your primary care physician or health insurer to see a specialist or receive a special test or procedure. Many commercial insurers require that you obtain a referral for most specialty care. It is important to know what your health insurer’s rules and procedures are for referrals.
Schedule of Allowances: The set dollar amount the insurance policy covers for each procedure.
Self-Insured Health Plan: In this type of plan, an employer will pay for employees’ health care costs out of a fund that the company has set aside for medical expenses. Employers may contract with an outside organization, often an insurance company, to administer the plan. Under a federal statute known as ERISA, the U.S. Department of Labor has authority over self-insured employer health plans. Therefore, New York’s consumer protection and insurance laws do not apply.
Specialist: A doctor who has been specially trained in and practices a specific type of medicine other than primary care (e.g., cardiologists, dermatologists, gastroenterologists). If you are enrolled in an HMO, you usually will need a referral from your primary care physician to see a specialist.
Utilization Review (UR) Appeal: A UR Appeal occurs when a consumer asks an insurer to reconsider its refusal to pay for a medical service the insurer considers experimental, investigational, or not medically necessary.