Appeal The process of requesting a provider or health plan pay for a service for which payment has been denied.
Auto-Enrollment The automatic assignment of a person to a health insurance plan.
Broker A salesperson that has obtained a state license to sell and service health plan and insurer contracts.
Claim A request by an individual that his or her insurance company pay for medical services received.
COBRA Federally supported health care benefits for people whose employment has been terminated, or who have experienced other circumstances that lead to loss of coverage.
Copayment The set amount of money a health plan enrollee pays for a specific service.
Deductible The minimum amount of out-of-pocket expenses a health care plan enrollee must pay for medical services or medication before their plan begins to cover expenses.
Employee Assistance Program (EAP) Benefits that are designed for personal or family problems, including mental health, substance abuse and other problems.
Enrollee A subscriber or dependent that is eligible for coverage under a certain health care contract.
Exclusions Conditions or situations not covered under a certain contract or plan.
Fee-For-Service (FFS) A traditional method of payment for health care services where users pay for services rendered.
Flexible Spending Account (FSA) A plan that provides employees with the opportunity to set aside funds pre-tax for certain medical expenses.
Group Health Plan Health coverage to employees and their families, provided by an employer or employee organization.
Health Maintenance Organization (HMO) A type of U.S. health care coverage where subscribers are required to receive all of their health care from a provider within a given network.
Health and Human Services (HHS) The U.S. department that is responsible for health-related programs and issues.
Health Care Provider Providers of medical or health care.
Individual Plans A type of insurance plan for individuals and families not eligible for health care coverage through an employer.
Lifetime Limit A cap on the benefits available during a subscriber's lifetime under a given policy.
Managed Care Systems and techniques used to manage health care services.
Medicaid A federal and state program that helps with medical costs for some low-income individuals and families.
Medicare A federal program that helps cover the medical costs of elderly and disabled individuals.
Open Enrollment Period A period during which subscribers in a health program can revise their benefits.
Patient Assistance Programs Programs offered by pharmaceutical companies to provide free or low-cost medications to people who could not otherwise afford them.
Pre-Existing Condition A condition or illness that you have before enrolling in a health care plan.
Preferred Provider Organization (PPO) A type of health care plan where a group of doctors and hospitals agrees to render particular services to a group of people for a reduced cost. This type of insurance is generally more expensive than HMOs but offers subscribers more freedom to select physicians.
Premium The amount paid to a health care company for providing medical coverage under a contract.
Preventive Care Health care that emphasizes prevention, early detection and early treatment.
Primary Care Physician (PCP) A "generalist" physician who, under certain health care plans, is accountable for the total health services of enrollees.
Referral The process of referring a patient to another doctor for specific health care services.
State Health Insurance Assistance Program (SHIP) A state-run, federally funded program that provides free local health insurance counseling to Medicare subscribers.
Waiting Period The minimum amount of time an individual must wait before becoming eligible for specific benefits after coverage has begun.
Workers' Compensation Insurance that covers employees who get sick or injured on the job.
Health Care
Health Care Resources
Glossary of Health Care Terms
Adjustment/Discount
The portion of your bill that is adjusted in accordance to the contract between Stanford and your insurance company.
Amount Not Covered
The amount your insurance company will not pay, for example: deductibles, co-insurance, co-payments and other charges for services determined to be non covered as part of you benefit package.
Ancillary Services as Defined by the No Surprises Act
Ancillary services are defined under the No Surprises Act to include care related to emergency medicine, anesthesiology, pathology, radiology, and neonatology; care provided by assistant surgeons, hospitalists, and intensivists; and diagnostic services (including radiology and laboratory services). This means these types of providers—or, in some instances, the providers that offer these types of care—can never ask a patient to sign a consent waiver to be balance billed for services covered by the No Surprises Act.
Applied to Deductible
The portion of your bill, as agreed with your insurance company, that you owe your medical provider.
Assignment of Benefits
The transfer of the right for reimbursement directly to the provider of plan benefits from the insured person to a health care provider.
- Transferring rights allows the insurer to mail any benefit payment directly to the provider.
- This legal statement is usually in the initial paperwork requested by the health care provider and may be signed by the insured person or his/her legal spouse or guardian.
Authorization
Permission to provide referred or requested a service that is granted by one or more of the following:
- Health insurance plan, or
- Medical group or the hospital depending upon who is financially responsible for the requested or referred services that are to be performed.
Authorization Number
A number your insurance company issues that indicates your treatment has been approved.
Balance Billing
When a provider bills for the difference between the provider's charge and the payment received from the patient's insurance. For example, if the provider's charge is $100 and the insurance payment is $70, the provider may bill the patient for the remaining $30.
Benefit
The services that are covered under your insurance plan.
Bill/Statement
A printed summary of the medical services you received.
Birthday Rule
Used to determine primary and secondary coverage for children. The word "birthday" refers only to the month and day
in a calendar year, not the year in which the person was born.
- If the parents are not separated or divorced, the insurance of the parent whose birthday occurs first in a calendar year is considered the primary insurance while the other parent's benefits are considered the secondary coverage.
- If the parents have the same birthday, the insurance plan that has covered the parent for the longest time is considered the primary insurance.
- In situations where the parents are separated or divorced and there is more than one insurance plan covering the child, the benefits are determined in the following order. **
- The insurance plan of the parent with legal custody of the child.
- The plan of the spouse of the parent with legal custody of the child.
- Last is the plan of the parent who does not have legal custody of the child.
- ** There can be some discrepancy, depending on a court decree, if there are no specific terms on a court decree (stating only that the parents share joint custody), the benefit determination would be the same as the first bullet above where if the parents are not separated or divorced, the insurance of the parent whose birthday occurs first in a calendar year is considered the primary insurance while the other parent's benefits are considered the secondary coverage.
California Children Services (CSS)
The California Children Services (CCS) Program provides diagnostic and treatment services, medical case management, physical and occupational therapy services to children under the age of 21 years with CCS-eligible conditions. Please provide an authorization from CCS.
Claim
The bill for your services that the hospital and/or physician sends to your insurance company for payment.
Co-insurance
The portion of your covered services that your insurance company requires you to pay after meeting your deductible.
Co-payment
A set fee established by your insurance company for a specific type of visit.
Consumer Protection Disclosure
The No Surprises Act requires providers and facilities to provide a Consumer Protection Disclosure to patients about their balance billing protections under the act. The Consumer Protection Disclosure includes information on:
- When there are bans on balance billing
- Any state laws that protect you from balance billing
- What state or federal agency to contact if you think your provider or hospital has not followed the bans on balance billing.
- Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate (“Good Faith Estimate”) of the bill for medical items and services
Consumer Protection Disclosure »
Right to Receive a Good Faith Estimate »
Learn more »
Coordination of Benefits (COB)
A group policy provision which helps determine the primary carrier in situations where an insured is covered by more than one policy.
Covered Services
A health care service, your insurance company agrees to pay a pre-established rate and/or percentage for.
Date of Service (DOS)
The date you were provided healthcare services.
Deductible (DED)
The amount of money, as determined by the benefit plan. A person must pay for authorized health care services before insurance payment commences. Deductibles are usually calculated on a calendar year basis, but can also be based on the anniversary date of a patient's effective date with that plan or plan year of the named insured or subscriber.
Exclusive Provider Organization (EPO)
There are two types of EPO plans.
- The current industry standard requires that a patient select a Primary Care Physician (PCP) (some patients may only have to choose a medical group) and when needed obtain authorization from that PCP to receive specialty services. A patient must stay within the contract network and only use preferred providers. There typically is a lifetime policy maximum with this type of plan. In the event a patient goes out of network (OON) they may be responsible for the entire balance that is not paid by the payer associated with the services provided.
- The other type of EPO is one where the benefits are those of a PPO but the provider panel from which members obtain care is smaller than a PPO panel.
Explanation of Benefits (EOB)
The notice you receive from your insurance company explaining how your claim was processed and/or paid. It will indicate the amount billed, paid, denied, discounted, not covered, and the amount owed by the patient.
Guarantor
The person or entity who is financially responsible for payment on a patient's account. Usually the patient is financially responsible for medical charges. A parent or legal guardian/trustee is the guarantor for patient's 18 years of age and younger. This is also the case for patients with a decreased mental capacity.
Inpatient (IP)
A patient is an inpatient when the physician orders an "inpatient admission."
Insured's Name (Beneficiary)
The name of the insured person.
In-Network Provider
Refers to providers or health care facilities that are part of a health plan’s network of providers. They are also called participating providers. Health plan members (patients) usually pay less when accessing an in-network provider because in-networks providers have negotiated fees for the health plan's members' covered services.
Medi-Cal
A California state sponsored medical assistance program enabling eligible recipients to obtain essential medical care and services.
Medi-Cal Managed Care
The conversion of fee-for-service Medi-Cal to PCP governed care whereby eligible select a primary care physician who manages all care provided to the members via treatment or referrals for treatment by specialists. Patients who do not follow the prescribed guidelines are responsible for all charges associated with that episode of care and are not covered by the state of Medi-Cal program.
Medicare
Medicare is a federal insurance program which primarily serves those over 65 years old and younger, disabled people and dialysis patients. Medicare is divided into two parts:
- Medicare Part A covers inpatient hospital services, nursing home care, home health care and hospice care.
- Medicare Part B helps pay the cost of doctors' services, outpatient hospital services, medical equipment and supplies and other health services and supplies.
Medicare Supplement
A supplemental private insurance policy to help cover the difference between approved medical charges and benefits paid by Medicare.
Network
A group of health care providers. It includes doctors, specialists, dentists, hospitals, surgical centers, and other facilities. These health care providers have a contract with the health insurance plan.
Non-Covered Services
A cost incurred by the patient when his/her insurance policy does not cover.
Out-of-Network (OON)/Non-Contracted Plan
Services rendered by a provider which does not have a contract to offer you care. Typically, managed care plans are contracted with a panel of providers. If a patient seeks care out-of-network, they may be financially responsible for some or all of the care provided. An exception to this rule is emergency medical care.
Out-of-Network Provider
Services rendered by a provider who is not a part of the health plan's contracted network of providers. If an individual seeks care out-of-network, he/she may be financially responsible for some or all of the care provided. An exception to this rule is emergency medical care.
The No Surprises Act is focused on these out-of-network provider charges/fees.
Learn more »
Out-of-Pocket Costs
The amount that is paid by the patient or guarantor.
Out-of-Pocket Maximum
The maximum yearly amount that is paid by the patient or guarantor.
Outpatient (OP)
A treatment or service you receive that does not require hospitalization.
Outpatient Hospital Departments
Outpatient hospital departments are those that meet the same higher standards for physical setting and patient care as required for a hospital. Most Stanford clinics--where we see our outpatients--are outpatient hospital departments.
Point of Service (POS)/Tiered Plan
Health coverage that allows the patient to utilize a variety of benefits associated with different level/tiers of coverage. The following is an explanation of the common tiered POS coverage.
- Tier 1 Level Benefits (HMO Coverage): members are assigned or chose a PCP; the PCP must manage the
care. Stanford Health Care must obtain authorization for specialty services. Typically, patients are only responsible for their co-pays.
- Tier 2 Level Benefits (PPO Coverage): the patient may self-refer to any in-network-contracted provider without obtaining authorization from their PCP but authorization is often required from the insurance company. Patients are responsible for a deductible and a percentage of their medical costs.
- Tier 3 Level Benefits: coverage for medical care provided to POS members from non-contracted provider. Insurance payment amount is dependent on the benefit offered by the plan. Services may be denied by the insurance company as not covered and the patient is responsible for 100% of all charges. Typically the patient is responsible for a larger share of the charges.
- Care provided to POS members without the required authorization from their health plan will result in the patient being financially responsible for 100% of the charges.
Policy Number
A number your insurance company gives you to identify you and/or your coverage.
Pre-Certification Number
This number represents the agreement by the insurance company that the services has been approved. This is not a guarantee of payment.
Pre-Existing Condition
A health condition or a medical problem acknowledged by your insurance company as not covered as a benefit.
Preferred Provider Organization (PPO)
- Health coverage that allows the member to direct his/her own healthcare.
- A patient may self-refer within a contracted network of physicians; after paying a deductible, a patient is commonly responsible for 10% or 20% of the allowable fee.
- A patient may choose to receive treatment from a provider outside of the PPO network thereby
increasing his/her deductible or out-of-pocket maximum.
- The patient may be responsible for obtaining authorization from the health plan for some services such as physical therapy and MRI services.
- There is typically a lifetime policy maximum associated with PPO coverage.
Primary Care Physician (PCP)
- The primary care physician (can be an internist, pediatrician, family physician, or OB/Gyn) is responsible for all
general medical care of the patients and referrals to specialists for tertiary care when medically appropriate.
- Most HMO, EPO and POS plans require members to choose or be assigned to a primary care physician.
- The PCP is responsible for providing or authorizing all care (hospitalization, diagnostic, workups and specialty referrals) for that patient
- Depending on the type of insurance plan, a patient may not be covered for a visit to a specialist without prior approval of the primary care provider.
Primary Insurance Company
The insurance company responsible for paying your claim first.
Prior Authorization
- A utilization control measure employed by PPO, EPO, HMO and POS plans, whereby, elective hospital admissions or other expensive medical services or procedures must be approved by the insurance company, medical group, gatekeeper or primary care
physician in advance.
- Such advance approval is known as prior authorization and is based on the insurance companies determination of medical necessity, appropriateness and other pertinent factors.
- Generally surgeries require prior authorization as do many procedures and tests done in the physician's office. A utilization review or prior authorization phone number is usually available from the insurance company to request authorization.
- For all emergency surgeries and admissions the provider must notify the insurance carrier of the patient's admission within 24 hours.
Provider
A hospital or physician who provides medical care to the patient.
Provider Charge
The amount of money the hospital or physician charges for a specific medical service.
Provider-Based Billing
Provider-based billing is another name for how Stanford bills for our hospital-designated clinics (see definition above). In brief, it's way that federal payers like Medicare use to recognize the higher standard of care provided in clinics like those at Stanford.
Reasonable and Customary (R&C)
The cost for medical services that insurance companies believe are appropriate throughout the geographic area or community.
Responsible Party/Guarantor
The person responsible to pay the bill.
Referral
A physician's medical order for services or consultations to be provided by a specialist.
Secondary Insurance
The insurance company responsible for paying the balance of your claim after the primary insurance company has determined benefits.
Self-Pay
If you do not have insurance, or if you are seeking care at Stanford Health Care and Lucile Packard Children's Hospital outside of your insurance plan benefits, you are considered a self-pay patient. The Stanford Health Care and Lucile Packard Children's Hospital self-pay policy requires full payment within 30 days of billing.
Share of Cost (SOC)
The amount a beneficiary must pay toward their health care costs before Medi-Cal will pay. The SOC may change when monthly income changes.
Subscriber
A person who is enrolled for benefits with an insurance company. One subscriber may represent.
- Health coverage that allows the member to direct his/her own healthcare.
- A patient may self-refer within a contracted network of physicians; after paying a deductible, a patient is commonly responsible for 10% or 20% of the allowable fee.
- A patient may choose to receive treatment from a provider outside of the PPO network thereby several members, such as dependents who are covered by their parents.
Surprise Billing
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
Surprise Billing Protection Form
Refers to a form used as part of the notice and consent process (as mandated by the No Surprises Act) to provide a Good Faith Estimate on the charges for the services sought, and allows a patient to waive their balance billing protections (agree to be balance billed for the out-of-network care).
Learn more »
Total Charges
The total price of your medical services.
Usual and Customary (U&C)
The cost for medical services that insurance companies believe are appropriate throughout the geographic area or community.
Worker's Compensation
The cost for medical services that insurance companies believe are appropriate throughout the geographic area or community.