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.
Advanced Directive—You are also asked about an Advanced
Directive when you register for inpatient or outpatient hospital
services. Formal Advanced 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
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
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
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
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
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
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
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
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.
For more information, call 1.866.CALL.MLH.