Glossary of Billing Terms
Adjustment: A portion of your bill that is reduced in accordance with the contract between MemorialCare and your insurance company.
Amount Not Covered: This is the billed amount that the insurance company will not pay. It may include deductibles, coinsurances, and charges for non-eligible services under your plan.
Amount Payable by Plan: The amount your insurance plan pays for your treatment, less any deductibles, coinsurance, or charges for non-covered services.
Assignment of Benefits: This is the transfer of the right for reimbursement directly to the hospital or provider from the patient’s health care provider. Transferring rights allows the insurance company to send any payment directly to the hospital or provider.
Authorization: Permission for patient services that is granted by the health insurance plan, medical group or the hospital.
Birthday Rule: Used to determine primary and secondary coverage for children when two parents have insurance coverage. The word "birthday" refers only to the month and day in a calendar year, not the year in which the person was born.
California Children Services (CCS): The California Children Services (CCS) Program provides diagnostic and treatment services, Medi-Cal case management, physical and occupational therapy services to children under the age of 21 years with CCS-eligible conditions. An authorization from CCS is required for services.
COBRA Insurance: Health insurance coverage that you can purchase when you are no longer employed, or awaiting coverage from a new insurance plan to begin. Coverage may be purchased for up to 18 months from your date of separation. It is generally more expensive than insurance provided through the employer but less expensive than insurance purchased as an individual policy.
Coinsurance: The percentage of costs not covered by your insurance benefits. For example, your policy may cover 80 percent of charges. Your coinsurance/patient portion is the remaining 20 percent.
Contracted Services: A contract between MemorialCare and a specific insurance company that specifies how much the insurance company will pay for certain medical services.
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. (See Birthday Rule for children with dual coverage.)
Co-payment/Co-pay: A set fee established by the insurance company for a specific type of visit. This amount is due from the guarantor. This information can usually be located on the insurance card, your insurance company's web site, or in your policy.
Date of Service (DOS): The date(s) when you were provided healthcare services. For an inpatient stay, the dates of service will be the date of your admission through your discharge date. For outpatient services, the date of service will be the date of your visit.
Deductible: An amount that must be paid on an annual basis. This amount is established by the insurance company and your benefit plan. Call your insurance company for the most up-to-date information regarding your deductible.
Delayed Charges: Occasionally, charges are posted to your account after billing. A follow up bill or statement should reflect all charges.
Explanation of Benefits (EOB): This is a notice you receive from your insurance company after your claim for healthcare services has been processed. It explains the amounts billed, paid, denied, discounted, non-covered, and the amount owed by the patient. The EOB may also communicate information needed from the insured in order to process the claim.
Health Maintenance Organization (HMO): An insurance plan that is contracted with providers such as MemorialCare to provide healthcare services at a discounted rate. These services require prior pre-certification, authorization, and/or referrals.
Medicaid: A state administered, federal and state-funded insurance plan for low-income families who have limited or no insurance. Medi-Cal is California’s Medicaid program.
Medi-Cal: Medi-Cal is California’s Medicaid program. Medi-Cal provides health services through a federal and state medical assistance program for eligible persons. Eligibility determination is conducted through the Department of Public Social Services. If you are covered under the Medi-Cal Program, you are required to provide an eligibility card or proof of eligibility for each month of service. For questions concerning Medi-Cal call 1-800-541-5555 or visit them on the web at www.dhs.ca.gov/mcs/medi-calhome/default.htm
Medi-Cal Managed Care: Contracts for health care services through established networks of organized systems of care, which emphasize primary and preventive care.
Medicare: A health insurance program for people age 65 and older, some people with disabilities under age 65, and people with end-stage renal disease (ESRD). For questions concerning the Medicare program, call the Social Security Administration toll-free at 1-800-MEDICARE, visit them on the web at www.medicare.gov, or call your local Social Security office.
Medicare Part A (Hospital Insurance): Healthcare coverage for inpatient stays at participating hospitals.
Medicare Part B (Medical Insurance): Healthcare coverage for doctors' services, emergency services, outpatient hospital care, and some other medical services that Part A does not cover, such as the services of physical and occupational therapists, and some home health care.
Medicare Summary Notice: A statement provided to patients or guardians by Medicare explaining how a claim was processed and paid.
Medicare Supplement: Insurance available by private insurance companies that pays for some services not covered by Medicare A or B, including deductible and coinsurance amounts.
Out-of-Network (OON): Services rendered by a provider that 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-Pocket Costs: The amount that is paid by the patient or guarantor outside the amount covered by insurance.
Pre-Authorization: Permission given by a health plan for a member to obtain services from a healthcare provider. This is commonly required for hospital services. Pre-Authorization/Certification is not a guarantee of payment by your insurance company.
Pre-Certification: Prior approval obtained from your insurance company by doctors and hospitals. This will represent the agreement by the insurance plan that the service has been approved. Your insurance may require your involvement in this process. Pre-Authorization/Certification is not a guarantee of payment by your insurance company.
Preferred Provider Organizations (PPO): An insurance plan that has a contract with providers to provide healthcare services. The patient may be responsible for obtaining approval prior to receiving services.
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 care when medically appropriate.
Primary Insurance Company: The first insurance company billed for the payment of the claim.
Self-Pay: If you do not have insurance, you are considered a cash paying patient. MemorialCare’s self-pay policy requires full payment at the time of service.
Share of Cost (SOC) for Medi-Cal: The amount a beneficiary must pay toward their health care costs before Medi-Cal will pay. This amount is determined by your social worker.
Subscriber: The person who is enrolled for benefits with an insurance company.
Supplemental Insurance: Insurance available by private insurance companies—that is usually secondary to Medicare—that may pay for some services not covered by Medicare A or B, including deductible and coinsurance amounts.
Worker’s Compensation: Worker's Compensation provides insurance coverage for work-related illnesses and accidents. In order to use this insurance you must provide the appropriate insurance information, including employer information, claim number and date of injury. This coverage is separate from regular medical coverage.