Definitions

2. Current Procedural Terminology Codes—Identifies the medical services or procedures performed. Describes medical, surgical, and diagnostic services.
4. The process insurance companies take to determine the order of responsibility for paying medical claims. This applies when you have more than one health insurance policy. Medicaid is always the payer of last resort.
5. Payer evaluation of the claim to determine if the claim is valid and how much of the claim will be reimbursed.
7. Standard claim form used by non-institutional providers or suppliers. Claims can be ambulance services, clinical social workers, physicians and their assistants, nurses (including clinical nurse specialists and practitioners, psychologists, and so forth.) Also known as a professional claim.
9. American Dental Association form. Standard claim form used by dental providers.
11. Code set with descriptive terms developed and updated by the American Dental Association (ADA) for reporting dental services and procedures to dental plans.
12. Dollar amount that you’re responsible to pay before insurance pays for any medical service in any given policy year.

1. Document from the insurance company that explains how a claim was processed that was submitted to the insurance company by the medical provider. Also called remittance advice.
2. Comes into play once you have satisfied your deductible. It’s a percentage of the allowed amount that you’re responsible for paying for a service.
3. International Classification of Diseases Codes. ICD-10 codes indicate why a billed procedure was performed. Also known as diagnosis codes.
6. Uniform medical billing form for institutional providers (hospital billing). Claims can be inpatient, outpatient, or mental health. Also known as an institutional claim. Often called a UB.
7. A fixed fee that you must pay for a medical service
8. Multiple billing codes that get paid together and are treated as though that they are one code. This often occurs in cases of surgeries.
10. Codes based on the CPT to provide standardized coding when healthcare is delivered. Generally used for equipment, drugs, and supplies.