Authorization is the approval of care, such as hospitalization. Pre-authorization may be required before admission takes place or care is given by non-HMO providers.
All charges not paid for by the insurance plan. Many insurance plans generally prohibit providers from balance billing except for allowed co-payments, coinsurance, and deductibles.
Certification is the authorization for health services.
Insurance claims can sometimes be reviewed before reimbursement is made from the insurance company to ensure medical appropriateness of the services and that rates are not excessive.
COB (Coordination of Benefits)
This is when a patient has more than one company for health insurance coverage. This ensures that a double payment is not made to us for services. For example, you may still be working and over the age of 65 and also covered by Medicare. It will be determined which insurance is primary for payment and which insurance has secondary responsibility.
Is a member’s coverage that limits the amount the insurance will pay for by a certain percentage, commonly 80%. Any additional costs are paid by the member which is usually around 20% of the cost of the medical services provided. The patient may also need to meet a deductible amount first.
This is a fixed amount of money, such as $15, for the patients responsibility of a claim or medical expense that must pay by the patient.
CPT-4 Code — Current Procedural Terminology
A set of five-digit codes that is used on the claim to inform the insurance company of what service was provided. Frequently used for billing professional services.
The portion of a member’s health-care expenses that must be met before your insurance coverage starts, can range from $100 to $5000. Some times it is common for an insurance plan to apply a different deductible for out-of-network services.
DRG (Diagnosis-Related Groups)
A system which classifies inpatient admissions into groups for purposes of payment to hospitals for Medicare patients, which can also be used by some private health plans.
EOB (Explanation of Benefits)
A statement mailed to a covered insured person explaining how and why a claim was or was not paid: the Medicare version is called an EOMB (also see ERISA).
A listing of the maximum fee that a health plan will pay for a certain service based on billing codes.
HCFA – 1500
A claims form used by professionals to bill for services. Required by Medicare and generally used by private insurance companies and managed care plans.
HMO (Health Maintenance Organization)
A health plan that has requires patients use a primary care physicians.
ICD-9-CM – International Classification of Disease
Diagnosis classification of diseases into 3 to 6-digit coding number.
Managed Health Care
Health care insurance in which the delivery of care is managed to control the costs of health care, the quality of that health care, and access to that care.
This is an insurance plan financed by both the federal government and the state programs, which provides health coverage to low income patients. Benefit coverage varies widely by each state.
A federal insurance program providing health insurance for people aged 65 and older, for disabled people and for those with Renal transplants. Medicare Part A covers hospitalization, Skilled Nursing Facilities, Home Health Care and Hospice services. Medicare Part B covers outpatient services and is a voluntary service.
Per Diem Reimbursement
Reimbursement of an institution based on a set rate per day rather than on charges. Per Diem reimbursement vary by service (e.g.. medical/surgical, obstetrics, mental health, and intensive care).
Reviewing patient’s diagnosis for hospital or outpatient admission before the patient actually has services rendered. This is used by insurance companies to eliminate unnecessary medical treatment or hospital expenses by denying medically unnecessary admissions. Failure to obtain authorization often results in the patient paying a high portion of the claim or the provider getting a reduced payment.
PPO (Preferred Provider Arrangement)
Insurance companies sometimes contract with providers at a discounted rate for services. A patient can use a provider outside of the PPO, but may have to pay a high co-insurance or deductible.
Skilled Nursing Facility (SNF)
A skilled nursing facility provides a high level of care for long-term or acute illness. It is an alternative to extended hospital stays or for difficult home care.
UCR (Usual, Customary, or Reasonable)
This is the contract rate a provider and insurance company agree upon for reimbursement usually the difference between what is charged and what the insurance company pays to the provider is the UCR.
A review by an insurance company for treatment patterns of particular providers to see how their usage of drugs, x-rays, lab tests and other services compares with their peers. Utilization Review affects the amount of income providers will receive from the HMO.
For more information
- Visit the Winona Health Hospital Business Office between 8 a.m. and 5 p.m., Mon-Fri
- Email us at: firstname.lastname@example.org
- Direct mail to: Business Office
P.O. Box 5600
Winona, MN 55987
- Phone: 877.201.3731 or 507.457.4579