Glossary of Medical Terms

 A  -   B   -  C   -  D   -  E  -  F  -   G  -   H  -   I   -  J   -  K   -  L  -   M  -   N  -   O  -   P -  

Q   -  R   -  S   -  T   -  U  -   V   -  W  -   X Y Z

 

A

Advance Beneficiary Notice (ABN)
This form is used to notify a Medicare beneficiary that certain equipment will not be covered by Medicare.  This form is completed prior to the equipment being shipped.

Advocate
A person who gives you support, protects your rights, and/or works on your behalf.

Allowable
The amount of money for which a third party payer will allow claim to be processed.  Often co-payments are based on allowable amounts.

Appeal

An appeal is a formal complaint made w2hen there is a disagreement with any decision made about your health care services.  For example, you would file an appeal if your insurance company refuses to authorize equipment that has been deemed medically necessary for you, and is covered under your policy.

 

Assignment of Benefits (AOB)

Form signed by the policy holder that allows the third party payer to pay the provider directly.  Without an AOB, payment might be sent to the policy holder.

  

B

Beneficiary

The formal name of the person who has health insurance through Medicare, Medicaid, and/or insurance.

  

C

Certificate of  Medical Necessity (CMN)

This state-specific form must be completed by the doctor and/or speech thereapist.

 
Claim

Billing submitted to the third party payer following delivery of services or products.

 

Client Information Form

This is the form that is usually completed by a family member or other contact person.  This form includes important information such as the client’s demographic information, physical information, the insurance information necessary for the funding department to process the funding request, and the shipping address where the client is requesting to have the equipment delivered.

 

Coinsurance

The percent of the approved amount that the client pays after the deductible is paid.

 

CPT Code

Current Procedural Terminology.  The code that describes the type of services that are being supplied.  This is generally the same as a HCPC code.

 

 

 

D

 

Deductible

The amount the client must pay yearly before a third party payer begins to pay.

 

Denial

A notice received following a request for the pre-certification/prior authorization from a third party payer.  The notice reflects the reviewers findings that the equipment prescribed is either found to not be medically necessary, or not covered by the policy.  The reason for the denial is stated within the documentation, and is sometimes successfully reversed through an appeal process.

 

Diagnosis

The name for the health problem that the client has.  Diagnosis is reflected by an ICD-9 code, which is an industry-wide code used to describe a client’s medical condition.

 

Durable Medical Equipment

Medical equipment that is ordered by a doctor for used in the home, and is reusable.  ACCI’s speech generating devices have been classified as Durable Medical Equipment.

 

 

 

E

 

Explanation of Benefits (EOB) Explanation of Medicare Benefits (EOMB)

A notice that is sent to the client after the doctor files the claim.  This notice explains what the provider billed for, the approved amount, how much as paid and what if anything the client owes.

 

Exclusions

Products and services for which the third party payer will not pay.

 

 

H

HCPC

Code that is used to describe the services rendered.  For example, the ALT-Chat Dedicated has an HCPC code of E2510.

 

Health Insurance Portability & Accountability Act  (HIPAA)

A law passed in 1996 which was designed to expand health care coverage for those that lose a job, or need to move from one job to another.  HIPAA protects clients who have pre-existing medical conditions and/or those having difficulty getting medical coverage.  HIPAA also mandates providers keep your medical information secure and private and establishes uniform coding throughout the industry in an attempt to reduce medical expenses derived from administrative processes.

 

 

I 

ICD-9 Code

International Classification of Diseases.  Insurance code that describes a client’s medical condition or diagnosis.

 

M

Maximum Out of Pocket

The maximum amount a client will pay toward their deductible and/or co-insurance during the year.

 

Medicaid

A joint federal and state program that heo0s with medical costs for some people with low incomes and limited resources.  Medicaid programs vary from state to state.

 

Medical Release

Written permission from the client and/or guardian to share private health information regarding the client with others.  Written permission is not required when a provider shares information with those identified as part of the client’s teams, and with third party payers.

 

Medically Necessary

Services or supplies that: are proper and needed for the diagnosis, or treatment of the client’s medical condition; are provided for the diagnosis, direct care, and treatment of the client’s medical condition, meet the standards of good medical practice in the local area; and are not mainly for the convenience of the client or doctor.

 

Medicare

The federal health insurance program for:  people 65 years of age or older and certain younger people with disabilities.

 

 

 N

National Provider Identifier (NPI)

This is a unique number assigned to various providers.  This number is needed when sending a claim to third party payers.

 

Non-participating Provider

Provider that has not contracted with a health insurance company to provide services at a reduced fee.  Also referred to as an out of network provider.

 

 

 O

 

Original Documentation

Prescription and speech evaluation that has an original signature.  The signature page on the evaluation and the doctor’s prescription cannot be copied or faxed.  Medicare requires that original documentation be on file with the provider.

 

P

Part B Medicare

Medicare medical insurance that helps pay for doctor’s services, outpatient hospital care, durable medical equipment (including speech generating devices), and some medical services that are not covered by Part A.

 

Place of Service

The location where the medical services will be provided to the client.  Coverage can depend on whether the client resides at home, in a group home, or in a nursing facility.  Clients residing in a Skilled Nursing Facility or Hospice are usually not eligible for speech generating devices.

 

Pre-certification, Prior Authorization

Approval issued by a third party payer before the equipment is provided.  The process usually entails completion of state forms and the attachment of documentation to prove medical necessity.

 

Primary Care Doctor, Primary Care Physician (PCP)

The primary care doctor is the doctor the client sees first for most health problems.  The PCP might refer the client to other specialists and must be seen before any other doctor is visited.

 

ProviderA doctor, hospital, health care professional, health care facility, or manufacturer of medical equipment.

 

S

Subscriber

The person covered under an employer’s insurance policy.  This person is identified as the policy holder.

 

Skilled Nursing Facility (SNF)

A nursing facility with the staff and equipment to give skilled nursing care and/or skilled rehabilitation services and other related health services.  In general, clients residing in a SNF do not qualify to receive benefits for speech generating devices under Medicare.

 

Speech Generating Devices (SGD)

The classification in which Medicare has placed augmentative communication devices.

 

T

Tricare

TRICARE is the health care program for active duty members of the military, military retirees, and their eligible dependents.  TRICARE was called CHAMPUS in the past.

 

 

 

U

 

UPIN

Unique Physician Identification Number.  Identification number that is used to identify the physician who wrote the prescription.  This number sometimes is required by various third party payers.