Insurance Vocab

ABN

Flip

Advanced beneficiary notice, also known as a waiver of liability, is a notice a provider should give a patient before receiving a service if, based on Medicare coverage rules, the provider has reason to believe Medicare will not pay for the service.

Back

Allowed amount

Flip

Maximum amount on which payment is based for covered health care services. This may be called “eligible expense,” “payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference.

Back

Appeal

Flip

A request for your health insurer or plan to review a decision or a grievance again.

Back

AUTH

Flip

Authorization. A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification.

Back

CMN

Flip

A certificate of medical necessity (CMN) is documentation from a doctor which Medicare requires before it will cover certain durable medical equipment (DME). The CMN states the patient's diagnosis, prognosis, reason for the equipment, and estimated duration of need.

Back

ConcurrenceStatement

Flip

Statement from the doctor agreeing with the mobility evaluation done by the PT or OT. Needed to bill insurance.

Back

Copay

Flip

A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.

Back

Co-insurance

Flip

Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay co-insurance plus any deductibles you owe. For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.

Back

Deductible

Flip

The amount you owe for health care services before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.

Back

Diagnosis

Flip

A diagnosis of a particular condition is usually necessary for insurance to cover the treatment.

Back

F2F

Flip

Face to face notes from the doctor are needed to bill insurance for Oxygen

Back

HCPC

Flip

HCPCs is a collection of standardized codes that represent medical procedures, supplies, products and services. The codes are used to facilitate the processing of health insurance claims by Medicare and other insurers.

Back

ICD-10

Flip

Codes we use in the system to identify Diagnoses and Symptoms for billing purposes

Back

Network

Flip

The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services. "In network" means they're contracted with your insurance, and your full benefits apply.

Back

OON

Flip

Out of network. This means that your insurance doesn't partner with a particular provider, and the "OON" stipulations of coverage will apply.

Back

Out of pocket limit/max

Flip

The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care your health insurance or plan doesn’t cover. Some health insurance or plans don’t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit.

Back

Premium

Flip

The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly.

Back

Prescription

Flip

Insurances need a valid prescription in order to cover the item or service.

Back

PCP

Flip

A primary care provider/physician (M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services.

Back