Click on the appropriate billing or insurance term for more information.
Certification is the authorization for health services.
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.
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.
A health plan that has requires patients use a primary care physicians.
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.
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.
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.
To learn more about healthcare pricing, click here to download a guide from the Healthcare Financial Management Association.
For more information
Winona Health, clinic 1st floor
855 Mankato Avenue • Winona, MN 55987
877.201.3731 or 507.457.4579
8 a.m.–5 p.m. Monday–Friday
P.O. Box 5600
Winona, MN 55987