, we realize families of patients are not always familiar with the terminology we use with reference to the billing process. This list of commonly used billing terms and their definitions will help guide you through the process.
Billing Statement Summary of patient account activity that is sent to parents or guardians updating them regarding the status of their claim.
Claim The information billed to the insurance company for services provided.
Contractual The difference between the insurance contracted amount and the amount of total charges.
Co-insuranceA percentage of allowable charges for which you are responsible as determined by your medical insurance policy.
Co-payment A set fee for a particular service as determined by your medical insurance policy
Deductible The amount that the patient or family must pay for health-care services before the insurance policy begins making payments. The health insurance policy sets this amount; usually it is due every calendar year.
EOB (Explanation of Benefits) A detailed explanation of coverage from the insurance company for the medical services provided.
Financial Assistance Adjustments made for qualified responsible parties, based on financial assistance applications and established financial guidelines.
Guarantor The individual responsible for payment of the bill.
Managed Care A medical delivery system that manages the quality and cost of medical services.
Medicaid The joint federal / state program that provides health care insurance to low-income families.
Out-of-Pocket MaximumAn out-of-pocket maximum is a cap on how much you have to pay for your family’s covered medical expenses in a calendar year. After you reach the out-of-pocket maximum, the plan pays 100% of all remaining covered expenses for that year.
Payment Arrangements A formal payment plan set up with Patient Accounts when the balance due cannot be entirely paid by the due date.
Payor A third party entity (commercial or government) that pays medical claims.
Prior Authorization / Precertification A formal approval obtained from the insurance company prior to delivery of medical services. Many insurance companies require prior authorization or precertification for specific medical services.
Subscriber The person who holds and / or is responsible for the medical insurance policy.