Medical Billing Terminology

Medigap​ - Medicare supplemental health insurance for Medicare beneficiaries which may include payment of Medicare deductibles, coinsurance and balance bills, or other services not covered by Medicare. 

Modifier​ - Modifier to a CPT treatment code that provide additional information to insurance payers for procedures or services that have been altered or "modified" in some way. Modifiers are important to explain additional procedures and obtain reimbursement for them. 

N/C​ - Non-Covered Charge. A procedure not covered by the patient's health insurance plan. 

NEC​ - Not Elsewhere Classifiable. Medical billing terminology used in ICD when information needed to code the term in a more specific category is not available. 

Network Provider​ - Health care provider who is contracted with an insurance provider to provide care at a negotiated cost. 

Nonparticipation​ - When a healthcare provider chooses not to accept Medicare-approved payment amounts as payment in full. 

NOS​ - Not Otherwise Specified. Used in ICD for unspecified diagnosis. 

NPI Number​ - National Provider Identifier. A unique 10 digit identification number required by HIPAA and assigned through the National Plan and Provider Enumeration System (NPPES).

OIG​ - Office of Inspector General - Part of department of Health and Human Services. Establish compliance requirements to combat healthcare fraud and abuse. Has guidelines for billing services and individual and small group physician practices. 

Out-of Network (or Non-Participating)​ - A provider that does not have a contract with the insurance carrier. Patients usually responsible for a greater portion of the charges or may have to pay all the charges for using an out-of network provider. 

Out-Of-Pocket Expense ​- The amount the patient is responsible to pay to the provider under their insurance policy. Anything above this limit is the insurers obligation. These Out-of-pocket maximums can apply to all coverage or to a specific benefit category such as prescriptions. 

Outpatient​ - Typically treatment in a physician's office, clinic, or day surgery facility lasting less than one day.

Palmetto GBA​ - An administrator of Medicare health insurance for the Centers for Medicare & Medicaid Services (CMS) in the US and its territories. A wholly owned subsidiary of BlueCross BlueShield of South Carolina based in Columbia, South Carolina. 

Patient Responsibility​ - The amount a patient is responsible for paying that is not covered by the insurance plan.

PCP​ - Primary Care Physician - Usually the physician who provides initial care and coordinates additional care if necessary. 

POS​ - Point-of-Service plan. Medical billing terminology for a flexible type of HMO (Health Maintenance Organization) plan where patients have the freedom to use (or self-refer to) non-HMO network providers. When a non-HMO specialist is seen without referral from the Primary Care Physician (self-referral), they have to pay a higher deductible and a percentage of the coinsurance. 

POS (Used on Claims)​ - Place of Service. 

Medical billing terminology used on medical insurance claims - such as the CMS 1500 block 24B. A two digit code which defines where the procedure was performed. For example 11 is for the doctors office, 12 is for home, 21 is for inpatient hospital, etc. 

PPO​ - Preferred Provider Organization. Commercial insurance plan where the patient can use any doctor or hospital within the network. Similar to an HMO.