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

completing CMS 1500 instruction - Field 1 - 13

Tips for Completing the CMS-1500 Claim Form

Member Information (Fields 1-13)

Field Number : 1
Field Description : Coverage
Data Type : Optional
Instructions : Show the type of health insurance coverage applicable to this claim by checking the appropriate box (e.g., if a Medicare claim is being filed, check the Medicare box).

Field Number : 1a
Field Description : Insured's ID number
Data Type : Required
Instructions : List the Insured’s identification number here. Verify that the identification number corresponds to the insured listed in item 4. The patient and the insured are not always the same person. Some payers assign unique identification numbers to each enrollee or dependent and require the number of the enrollee or dependent receiving services (the patient) instead of the insured’s number in this item.

Field Number : 2
Field Description : Patient's name
Data Type : Required
Instructions :  Enter the patient's last name, first name, and middle initial, if any.
NOTE: If the patient has a last name suffix (e.g., Jr, Sr) enter it after the last name, but before the first name. Do not use any punctuation in this field.

Field Number :  3
Field Description : Patient's birth date and gender
Data Type : Required
Instructions : Enter the patient's birth date and sex. Use the eight digit format (MM|DD|CCYY) format for date of birth. Enter an X in the correct box to indicate the sex of the patient. Only one box can be marked. If the gender is unknown, leave blank.



Field Number : 4