Medical Billing Terms and Definitions

The percentage you pay after an insurance company pays its agreed-upon percentage; e.g., your plan may cover 80% and you would pay the remaining 20%.

A dollar amount specified by your insurance plan that you pay for a medical visit. You may have a co-pay for a doctor visit, or for specific services rendered at a hospital such as emergency services.

A method of determining which insurance is to be billed first when a patient is covered by more than one insurance plan. This helps ensure that members covered by more than one plan will receive the benefits they are entitled to while avoiding overpayment by either plan and keeping premiums at a minimum.

A CPT (Current Procedural Technology) code utilizes a standardized coding system to communicate to an insurance company which specific services were provided to a patient.

The amount you need to pay before an insurance company begins to pay for services. This amount resets at the beginning of a new benefit period, usually annually.

A denial occurs when an insurance company denies coverage to pay for health care services that were provided to you by a licensed health care professional or facility.

A system of classifying the medical condition of the patient at the time of the service, which is produced using the medical documentation recorded at the time of service. This is added to the claim to help the insurance company understand the reason for the specific treatment.

Services that are provided in a hospital emergency room or in an urgent care setting.

Experimental or investigational medical treatment or procedures are those not approved by the Food and Drug Administration (FDA) and not considered to be a standard of care.

The person or group that assumes responsibility of payment for a debt owed to Celligent Diagnostics.

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law designed to protect the patient’s private health information.

A group of health care providers under contract with an insurance company pursuant to which the group offers health care services to plan members for specific pre-negotiated rates.

The services you received while you were admitted to the hospital.

Charges for services and supplies that are not covered under a health plan.

Hospital outpatient services provided by pathologists to help the doctor decide if a patient needs to be formally admitted to the hospital.

Health care providers outside of an established network.

The cost you would need to pay depending upon your plan. Costs vary by plan, and there is usually a maximum out of pocket cost.

When a patient is covered by more than one insurance plan, one insurer will become the primary carrier and all others will be considered secondary and tertiary carriers that will help cover remaining costs not covered by your primary insurer.

The services most frequently performed by physicians.

The portion of a patient’s bill that the patient (and/or the patient’s guarantor) is legally responsible for paying.