N
Non-Covered Charge (N/C): N/Cs are procedures and services not covered by a person’s health insurance plan.
Not Elsewhere Classifiable (NEC): A term used to describe a procedure or service that can’t be described within the available code set.
Network Provider: A provider within a health insurance company’s network that has contracted with the company to provide discounted services to a patient covered under the company’s plan.
Non-participation: This is when a provider refuses to accept Medicare payments as a sufficient amount for the services rendered to a patient.
Not Otherwise Specified (NOS): This term is used in ICD-9 codes to describe conditions with unspecified diagnoses.
National Provider Identifier (NPI) Number: A unique 10-digit number ascribed to every healthcare provider in the U.S. as mandated by HIPAA.
O
Office of Inspector General (OIG): The organization responsible for establishing guidelines and investigating fraud and misinformation within the healthcare industry. The OIG is part of the Department of Health and Human Services.
Out-of-Network: Out-of-network refers to providers outside of an established network of providers who contract with an insurance company to offer patients healthcare at a discounted rate. People who go to out-of-network providers typically have to pay more money to receive care.
Outpatient: This term refers to healthcare treatment that doesn’t require an overnight hospital stay, including a routine visit to a primary care doctor or a non-invasive surgery.
P
Palmetto GBA: A MAC based in Columbia, South Carolina that is also a subsidiary of Blue Cross Blue Shield.
Patient Responsibility: This refers to the amount a patient owes a provider after an insurance company pays for their portion of the medical expenses.
Primary Care Physician (PCP): The physician who provides the basic healthcare services for a patient and recommends additional care for more serious treatments as necessary.
Point of Service Plans: A plan whereby patients with HMO membership may receive care at non-HMO providers in exchange for a referral and paying a higher deductible.
Place of Service Code: A two-digit code used on claims to explain what type of provider performed healthcare services on a patient.
Preferred Provider Organization (PPO): A plan similar to an HMO whereby a patient can receive healthcare from providers within an established network set up by an insurance company.
Practice Management Software: Software used for scheduling, billing, and recordkeeping at a provider’s office.
Preauthorization: Some insurance plans require that a patient receive preauthorization from the insurance company prior to receiving certain medical services to make sure the company will cover expenses associated with those services.
Pre-Certification: A process similar to preauthorization whereby patients must check with insurance companies to see if a desired healthcare treatment or service is deemed medically necessary (and thus covered) by the company.
Pre-determination: A maximum sum as explained in a healthcare plan an insurance company will pay for certain services or treatments.
Pre-existing Condition (PEC): PEC is a medical condition a patient had before receiving coverage from an insurance company. A person might become ineligible for certain healthcare plans depending on the severity and length of their PEC.
Pre-exisiting Condition Exclusion: The existence of a PEC denies a person certain coverage in some health insurance plans.
Premium: The sum a person pays to an insurance company on a regular (usually monthly or yearly) basis to receive health insurance.
Privacy Rule: Standards for privacy regarding a patient’s medical history and all related events, treatments, and data as outlined by HIPAA.
Provider: A provider is the healthcare facility that administered healthcare to an individual. Physicians, clinics, and hospitals are all considered providers.
Provider Transaction Access Number (PTAN): This refers to a provider’s current legacy provider number with Medicare.
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