Advance Beneficiary Notice (ABN): A form signed by the patient before certain services are rendered, notifying him/her that Medicare may not cover this service and that the patient will be responsible for payment. The ABN was previously called the Medicare Medical Necessity Waiver.
Assignment of Benefits: An agreement in which you instruct your insurance organization to pay the hospital, physician or medical supplier directly for your medical services. Your insurance organization decides the payment rate.
Balance: The amount owed to Lafayette General Health indicated on the billing statement.
Commercial Health Insurance: Private or employer base health insurance.
Co-payment/Coinsurance: An amount established by the insurance company as the patient’s responsibility of billed fees.
Coordination of Benefits (COB): How insurance organizations determine the primary payment source when you’re covered under more than one insurance or group medical plan. Your insurance contract states that if you are covered under more than one insurance plan, benefits will be coordinated so that total benefits paid will not be more than 100% of the bill. COB for children covered by both parents is determined by the parent with the earliest birthday (month and day only) in a calendar year.
Covered Services: Specific services or supplies for which insurance reimburses you or pays your health care provider. These consist of a combination of mandatory and optional services and vary by insurance benefit plan.
Deductible: An amount determined by the insurance company to be paid on an annual basis before benefits are paid.
Disallowed Amount: The difference between the charge and the amount your insurance organization approves. If your healthcare provider is under contract with your insurance organization to accept the approved amount, you are not billed for the difference. If your provider is not under contract, you may be billed for this difference.
DOS: Date of Service.
Elective Services: Any service that is not emergency care. With few exceptions, cosmetic procedures are elective services and must be prepaid by the patient.
Explanation of Benefits (EOB)/Medicare Summary Notice: A document provided by the patient’s insurance plan/Medicare detailing how benefits are processed and paid for services rendered.
Financial Number: Your account number with your healthcare provider, a different number is assigned for each visit.
Guarantor: The person responsible for paying the bill.
Non-covered Services: A service not covered under the limits of the patient’s health insurance contract. These amounts are the patient’s responsibility to pay. Patients should direct questions about coverage to their insurance plan.
Non-Participating Healthcare Provider: A healthcare provider who isn’t under contract with an insurance organization to accept patients and receive the insurance organizations approved amount on all claims. (You pay the difference between its approved amount for a service and this health care provider’s charge.)
Participating Healthcare Provider: A health care provider who contracts with an insurance organization to accept patients and receive the insurance organizations approved amount on all claims.
Pre-Authorization/Pre-Certification: Requirement of your insurance company to determine medical necessity for services rendered. Pre-certification does not guarantee benefits for payment. Benefits are based on policy provisions in force at the time services are rendered. Questions about pre-certification requirements in your contract should be directed to your insurance plan.
Primary Insurance: The insurance organization with first responsibility for paying eligible insurance expenses for your medical service (after you have paid your deductible, co-payments, etc.). Your secondary or other insurance would work with your primary insurance organization to cover eligible expenses according to your insurance policies.
Proof of Health Insurance: A valid insurance card including the address where claims are to be filed.
Referral: Written authorization from your healthcare provider to see another provider. For example, your primary care provider may provide written authorization for you to see a specialist.
Secondary Insurance: The insurance organization with second responsibility for paying eligible insurance expenses for your medical service (after you have paid your deductible, co-payments, etc.). This insurance would work with your primary insurance organization to cover eligible expenses according to your insurance policies. This insurance organization is billed second – after primary insurance organization has been billed and processed your claim.
Statement: A record of account status sent to patients monthly to advise of the previous period’s transactions and activity on the account.
Tertiary Insurance: The insurance organization with third responsibility for paying eligible insurance expenses for your medical service (after you have paid your deductible, co-payments, etc.). This insurance would work with your primary and secondary insurance organizations to cover eligible expenses according to your insurance policies. This insurance organization is billed third – after your primary and secondary insurance organizations have been billed and processed your claim.
Uninsured Patient: A patient without medical insurance.
Utilization Limits: Medicare sets limits on how many times some services can be provided in a year. If services exceed this utilization limit, your claim could be denied. These limits are not disclosed to Lafayette General Health.