Medical billing basic terms

Practice Management Software​ - software used for the daily operations of a provider's office. Typically used for appointment scheduling and billing. 

Preauthorization​ - Requirement of insurance plan for primary care doctor to notify the patient insurance carrier of certain medical procedures (such as outpatient surgery) for those procedures to be considered a covered expense. 

Pre-Certification​ - Sometimes required by the patients insurance company to determine medical necessity for the services proposed or rendered. This doesn't guarantee the benefits will be paid.

 Predetermination​ - Maximum payment insurance will pay towards surgery, consultation, or other medical care - determined before treatment. 

Pre-existing Condition (PEC)​ - A medical condition that has been diagnosed or treated within a certain specified period of time just before the patients effective date of coverage. A Pre-existing condition may not be covered for a determined amount of time as defined in the insurance terms of coverage (typically 6 to 12 months). 

Pre-existing Condition Exclusion​ - When insurance coverage is denied for the insured when a pre-existing medical condition existed when the health plan coverage became effective. 

Premium​ - The amount the insured or their employer pays (usually monthly) to the health insurance company for coverage. 

Primary Subscriber​ (Insured) - The person under whom the insurance policy is obtained. 

Privacy Rule​ - The HIPAA privacy standard establishes requirements for disclosing what the HIPAA privacy law calls Protected Health Information (PHI). PHI is any information on a patient about the status of their health, treatment, or payments. 

Provider​ - Physician or medical care facility (hospital) who provides health care services. 

PTAN​ - Provider Transaction Access Number. Also known as the legacy Medicare number. 

Referral​ - When one provider (usually a family doctor) refers a patient to another provider (typically a specialist). 

Remittance Advice (R/A)​ - A document supplied by the insurance payor with information on claims submitted for payment. Contains explanations for rejected or denied claims. Also referred to as an EOB (Explanation of Benefits). 

Responsible Party​ - The person responsible for paying a patient's medical bill. Also referred to as the guarantor. 

Scrubbing​ - Process of checking an insurance claim for errors in the health insurance claim software prior to submitting to the payer. 

Self-Referral​ - When a patient sees a specialist without a primary physician referral.

Self Pay​ - Payment made at the time of service by the patient. 

Secondary Insurance Claim​ - claim for insurance coverage paid after the primary insurance makes payment. Secondary insurance is typically used to cover gaps in insurance coverage. 

Secondary Procedure​ - When a second CPT procedure is performed during the same physician visit as the primary procedure.

Security Standard​ - Provides guidance for developing and implementing policies and procedures to guard and mitigate compromises to security. The HIPAA security standard is kind of a sub-set or complement to the HIPAA privacy standard. Where the HIPAA policy privacy requirements apply to all patient Protected Health Information (PHI), HIPAA policy security laws apply more specifically to electronic PHI.