Glossary of Billing Terms
Advance Beneficiary Notice (ABN): A form signed by the patient before certain services are rendered, notifying him/her that Medicare may not cover this service, and that the patient will be responsible for payment.
Balance: The amount owed to Spectrum Medical, Inc. indicated on your billing statement.
Commercial Insurance: A private insurance contract. (not Blue Cross/Blue Shield, Medicare, Medicaid or Tricare)
Co-payment/Coinsurance: The patient’s responsibility of the billed fees as established by the insurance company.
Deductible: The amount to be paid by the patient yearly before the insurance company will pay benefits. This is determined by the insurance company and your policy.
DOS: Date of Service
Explanation of Benefits (EOB): A document provided by the patient’s insurance company (Medicare) showing details of how your benefits paid for purchased item or service rendered.
Noncovered Services: A service that is deemed not covered by your Insurance Company Plan. All noncovered services are the patient’s responsibility to pay.
Nonparticipating Provider: A health care provider who chooses to not accept the insurance/Medicare approved amount as payment in full. The patient will owe a balance for services.
Pre-Certification/Prior Authorization: An insurance company requirement to determine medical necessity for services rendered. This must be completed before items/services are received by the patient. This does not guarantee payment.
Proof of Health Insurance: A valid insurance card which includes date of coverage and address where claims are to be filed.
Self-pay Patient: A person who has no health insurance coverage or chooses not to have chares filed with his/her insurance company. This patient is to pay for services at the time the service is rendered.
Statement: A record of your account activity in the last thirty days and your current balance. This is mailed to patients monthly.
Uninsured Patient: A patient without medical insurance. These patients are responsible for payment in full.
Usual and Customary (UCR): Predetermined allowable limits used by insurance companies to limit the maximum amount they will pay on a specific service/product as governed by their contract with the patient. Please note that Spectrum Medical Inc. does not accept predetermined UCR amounts for health plans with which we do not participate.
Utilization Limits/Maximum Benefit: Medicare sets limits on how many times some services/products can be provided in one month/year. If services exceed this limit, your claim may be denied. The insurance companies do not always inform Spectrum Medical Inc. of these amounts.
