Advanced beneficiary notice (ABN) – A form advising you that the test/procedures performed may not be covered by Medicare. The purpose of the ABN is to let you know in advance that these services may not be covered and to advise you that you may be responsible for payment of these related charges. An ABN gives you the option to accept or refuse the items or services in cases where Medicare denies payment.
Advance directive – You are also asked about an advance directive when you register for inpatient or outpatient hospital services. Formal advance directives are documents written in advance of serious illness that state your choices for health care, or name someone to make those choices, if you become unable to make decisions. Medicare and hospital accrediting bodies (organizations that oversee the quality of care provided by hospitals) require we ask each patient, at each visit, whether or not the patient has a current advance directive. This could be in the form of a living will, health care power of Attorney, or both. Through these documents you can make legally valid decisions about your future medical treatment.
Adjustment – A portion of your hospital bill that is adjusted in accordance with the contract between MLH and your insurance company.
Beneficiary – someone who is eligible for or receiving benefits under an insurance policy or plan.
Birthday rule – The birthday rule is endorsed by the National Association of Insurance Commissioners (NAIC). The birthday rule states that the plan of the parent whose date of birth (month and day) falls earlier (or first) in the calendar year is the primary plan for dependent children.
Children's Health Insurance Program (CHIP) – A federal program jointly funded by states and the federal government, which provides medical insurance coverage for children not covered by state Medicaid-funded programs.
Consent to treatment/financial obligations – Each patient signs a consent to treatment/financial obligations form. This is signed at time of registration. This is an opportunity to ask any questions related to your treatment as well as your financial obligations for that treatment.
Consolidated Omnibus Budget Reconciliation Act (COBRA) – A federal law that requires employers to offer continued health insurance coverage to certain employees and their beneficiaries whose group health insurance coverage has been terminated. Typically, COBRA makes continued coverage available for up to 18 or 36 months.
Co-insurance – A type of cost sharing where the beneficiary and insurance provider share payment of the approved charge for covered services in a specified ratio after payment of the deductible by the insured. For example, your policy may cover 80 percent of charges. Your coinsurance/patient portion would be the remaining 20 percent.
Co-pay – A fixed dollar amount set by the insurance company for the specific type of visit. This information can routinely be located on the insurance card and will be different according to the type of visit. For example, Emergency Room Visit, Inpatient Stay, Physician Office Visit (PCP), Specialist Office Visit.
Coordination of benefits (COB) – Coordination of benefits is the determination of which insurance pays: primary, secondary, or tertiary.
Deductible – A type of cost sharing where the beneficiary pays a specified amount of approved charges for covered medical services before the insurer will pay for all or part of the remaining covered services. Usually the deductible needs to be met and paid by the patient each year.
Explanation of benefits (EOB) – A notice you may receive from your insurance company after your claim for health care services has been processed. It explains the amounts billed, paid, denied, discounted, and the amount owed by the patient. The EOB may also communicate information needed by the insured in order to process the claim.
Guarantor – The individual who is assuming financial liability for the patient’s account.
Health Maintenance Organization (HMO) – An entity that provides, offers or arranges for coverage of designated health services needed by plan members for a fixed, prepaid premium. An insurance company is contracted with providers to provide health care services at a discount. Many services require prior authorization, pre-certification, and referral.
Health Insurance Portability and Accountability Act (HIPAA) – HIPAA is a Federal law designed in part to safeguard patients’ personal, protected health information (PHI).
ICD-9 Codes – International Statistical Classification of Diseases and Related health Problems. Under this system every health condition can be assigned to a unique category and given a code, up to six characters long. This information is requested by the provider from the physician ordering a test, and should be indicated on your prescription. Our registration department will request this information when you schedule an appointment.
Medicaid – A state administered federal and state-funded insurance benefit program for low-income families who have limited or no insurance. Each state sets its own eligibility standards.
Medicare – A federal health benefit program for people age 65 and older, people with disabilities under age 65, and people with end-stage renal disease.
Medicare secondary payer questionnaire (MSP) – If you are a Medicare beneficiary, you will also be asked to complete a Medicare Secondary Payer or MSP questionnaire. Medicare pays for your care only after all other available insurance is exhausted. To determine whether or not you have any other source of insurance, Medicare requires a beneficiary to complete an MSP for every admission, outpatient encounter or start of care. There are a few exceptions to this rule for lab services and recurring services like physical therapy.
Medicare advantage plan – Are health plan options that are part of the Medicare program offered by private insurers. If you join one of these plans, you generally get all your Medicare-covered health care through that plan. This coverage can include prescription drug coverage.
Part A Medicare (Hospital Insurance) – Covers Medicare beneficiaries for inpatient hospital, home health, hospice and limited skilled nursing facility services. Beneficiaries are responsible for deductibles and co-payments.
Part B Medicare – Covers Medicare beneficiaries for physician services, medical supplies and other outpatient treatment. Beneficiaries are responsible for monthly premiums, co-payments, deductibles and balance billing.
Medigap insurance (supplemental) – Privately purchased individual or group health insurance policies designed to supplement Medicare coverage. Benefits may include payment of Medicare deductibles, co-insurance and balance bills, as well as payment for services not covered by Medicare.
Network – A group of doctors, hospitals, pharmacies, and other health care experts who work under a contract with a health plan.
Out of Network (OON) – Coverage for treatment obtained from a non-participating provider. Typically, it requires payment of a deductible and higher co-payments and co-insurance than for treatment from a participating provider.
Notice of Privacy Practices (NPP) and Acknowledgement – All patients are provided the Main Line Health Notice of Privacy Practices during the first visit to a Main Line Health Facility. To make sure that patients understand their rights related to the use and disclosure of PHI, HIPAA rules require that each patient receive a copy of the facility’s NPP on their first visit. The facility is also required to get an acknowledgement from each patient that a copy of the NPP was given to them.
Point-of-Service Plan (POS) – A health benefit plan allowing the covered person to choose to receive a service from a participating or non-participating provider, with different benefit levels associated with the use of participating providers.
Pre-certification number – A number obtained from your insurance company by doctors. This number will represent the agreement by the insurance plan that the service has been approved. This is not a guarantee of payment. This authorization number will be requested by Main Line Health if your insurer requires pre-cert for the procedure.
Pre-existing condition – A medical condition that occurred before a program of health benefits went into effect.
Preferred Provider Organization (PPO) – a program that establishes contracts with health care providers. Providers under such contracts are referred to as a preferred provider. Usually, the benefit contract provides significantly better benefits and lower member costs for services received from preferred providers, thus encouraging covered persons to use these providers.
Prescription or order – A written description of the care and treatment that the hospital is to provide to you. Private insurers, government payors, state law, and government regulations all require an order signed by your physician. This prescription or order is required at time of scheduling and at time of test for outpatient studies.
Referral – Most managed care plans, health maintenance organizations (HMOs), and point of service plans (POS) require that your primary care physician refer you to receive specialty care. Each plan is different and it is your responsibility to know the requirements for your plan and obtain any necessary referrals.
Workers’ compensation – provides health care benefits if you are injured or become ill on the job due to workplace exposure. Workers’ Compensation does not replace your regular health insurance. More information can be obtained by contacting the PA Bureau of Workers’ Compensation at 800.482.2383.