Glossary of Insurance and Medical Billing Terms

D 

Deductible The amount an insured member must pay before the insurance company begins covering health care costs. 

DHS Department of Health Care Services for California www.dhcs.ca.gov 

Diagnosis Code ICD-9 code used to describe illness, injury or diseases 

DME Durable Medical Equipment 

DOS Dates of Service -- The date(s) when a patient was treated. 

E

 EDI Electronic Data Interchange

 EFT Electronic Funds Transfer -- A paperless computerized system enabling funds to be debited, credited, or transferred from the payer. 

EIN Employer Identification Number -- Also known as Tax Identification Number (TIN) 

EMR Electronic Medical Records -- Medical record in electronic format. 

EOB Explanation of Benefits -- Details regarding how your insurance company processed medical insurance claims, explains what portion of a claim was paid to the health care provider and what portion of the payment. 

EPSDT Early and Periodic Screening, Diagnosis, and Treatment -- A Medi-Cal program for individuals under the age of 21 who have full-scope Medi-Cal eligibility. This program allows for periodic screening to determine health care needs. 

ERA Electronic Remittance Advice -- Electronic file supplied by the payer to outline payment for submitted claims. Also known as an 835 file.

F 

Fee for Service A method of payment for medical services rendered 

Fee Schedule A list of CPT codes and dollar amounts an insurance company will pay for a particular medical service

Formulary List of prescription drugs cost of which an insurance company will reimburse, or those that will provided free under a scheme. 

G 

GPNet The EDI gateway to Palmetto GBA

 H

 HCPCS Healthcare Common Procedure Coding System -- 5-digit alphanumeric set of procedure codes based on the AMA CPT codes. A standardized medical coding system for describing the specific items and services provided in the delivery of health services. Also known as a Procedure Code. 

HIPAA Health Insurance Portability and Accountability Act. This federal act sets standards for protecting the privacy of your health information. 

HL7 Health Level Seven -- A data exchange protocol and interface for medical records and billing software that allows different systems to interoperate. 

HMO Health Maintenance Organization -- An insurance plan that pays for preventative and other medical services provided by a specific group of participating providers.

I 

ICD-9 International Classification of Diseases -- A standard format to describe the illness, injury or diseases by using a three digit code. Also known as a Diagnosis Code. 

IPA Independent Practice Association -- An organization of physicians who are contracted with an HMO plan 

IVR Interactive Voice Response -- Palmetto GBA 24 hour telephone line, obtain Medicare Part B information, such as claim status, last 3 checks issues, and eligibility. 

J 

Jurisdiction 1 California, Hawaii, Nevada, Guam, American Samoa, Northern Mariana Islands