Reference
Patient Advocate Glossary
67 plain-language definitions of coverage, billing, Medicare, appeals, privacy and care terms you can share with clients.
Showing 67 of 67 terms
A
- Advance Beneficiary Notice (ABN)Medicare & Medicaid
- A notice a provider gives a person with Original Medicare before a service Medicare may not cover, so they can decide whether to proceed and pay.
- Advance directiveCare & practice
- Written instructions about future medical care, such as a living will or health care power of attorney.
- Allowed amountBilling & claims
- The maximum a plan will pay for a covered service; may differ from the provider's billed charge.
B
- Balance billingBilling & claims
- When a provider bills a patient for the difference between its charge and the plan's allowed amount.
- BCPACare & practice
- Board Certified Patient Advocate, the credential awarded by the Patient Advocate Certification Board (PACB).
- Business associateRecords & privacy
- A person or company that handles PHI on behalf of a covered entity, under a business associate agreement.
C
- Care coordinationCare & practice
- Organizing a patient's care across providers so information is shared and services are not missed or duplicated.
- Charity careBilling & claims
- Free or discounted hospital care for eligible patients based on income, under the hospital's financial assistance policy.
- COBRAInsurance & coverage
- A federal law letting people keep employer coverage for a limited time after leaving a job, usually at full cost.
- CoinsuranceInsurance & coverage
- The patient's percentage share of a covered service's cost, usually after the deductible is met.
- Coordination of benefitsInsurance & coverage
- Rules deciding which plan pays first when a person has more than one source of coverage.
- Copayment (copay)Insurance & coverage
- A fixed dollar amount a patient pays for a covered service, such as a doctor visit or prescription.
- Covered entityRecords & privacy
- A health plan, clearinghouse or provider that conducts certain electronic transactions and must follow HIPAA.
- CPT / HCPCS codeBilling & claims
- Standard codes describing the procedures, services and supplies billed on a claim.
D
- DeductibleInsurance & coverage
- The amount a patient pays for covered services each plan year before the plan starts paying its share.
- Designated record setRecords & privacy
- Records a covered entity uses to make decisions about individuals; the scope of the right of access.
- Discharge planningCare & practice
- The process of preparing a patient to leave the hospital safely, including follow-up care and services.
- Dual eligibleMedicare & Medicaid
- A person enrolled in both Medicare and Medicaid.
E
- Engagement agreementCare & practice
- A written contract between an independent advocate and client setting out services, fees, limits and privacy terms.
- ERISA planInsurance & coverage
- An employer-sponsored plan governed by federal law; self-funded ERISA plans are generally not regulated by state insurance departments.
- Expedited (urgent) appealAppeals & rights
- A faster appeal when waiting the standard time could seriously harm the patient's health.
- Explanation of Benefits (EOB)Billing & claims
- A plan statement explaining how a claim was processed and what the patient may owe. It is not a bill.
- External reviewAppeals & rights
- An independent review of a plan's denial after internal appeals, by a reviewer outside the plan.
- Extra Help (LIS)Medicare & Medicaid
- A Medicare program that lowers Part D premiums and drug costs for people with limited income and resources.
F
- Facility feeBilling & claims
- A charge some hospitals and hospital-owned clinics add for use of their space, separate from the clinician's fee.
- Fair hearingAppeals & rights
- A Medicaid appeal before a state hearing officer, with strict deadlines stated on the notice.
- Financial assistance policy (FAP)Billing & claims
- A nonprofit hospital's written charity-care policy required under IRS section 501(r).
- FormularyInsurance & coverage
- A plan's list of covered prescription drugs, often grouped into tiers with different cost-sharing.
G
- Good Faith EstimateBilling & claims
- A required estimate of expected charges for uninsured or self-pay patients under the No Surprises Act.
- GrievanceAppeals & rights
- A formal complaint about a plan or provider, such as service quality or access, separate from a coverage appeal.
H
- Health care proxyCare & practice
- A person legally named to make health care decisions if the patient cannot; called a health care agent or power of attorney in some states.
- HIPAARecords & privacy
- The federal law setting privacy and security rules for health information held by covered entities and their business associates.
- HIPAA authorizationRecords & privacy
- A signed form allowing a covered entity to share a patient's PHI with a named person, such as an advocate.
I
- ICD-10 codeBilling & claims
- Standard diagnosis codes used on claims to explain why a service was provided.
- In-network / out-of-networkInsurance & coverage
- Whether a provider has a contract with the patient's plan. Out-of-network care usually costs more or may not be covered.
- Informed consentCare & practice
- A patient's agreement to a treatment after being told its purpose, risks, benefits and alternatives.
- Internal appealAppeals & rights
- A request asking the plan itself to reconsider a denied claim or service.
- Itemized billBilling & claims
- A detailed bill listing each charge, code and date of service; the starting point for checking billing errors.
L
- Letter of medical necessityAppeals & rights
- A clinician's letter explaining why a service or drug is needed, often used in appeals and prior authorizations.
M
- MedicaidMedicare & Medicaid
- A joint federal–state program covering eligible people with limited income; rules vary by state.
- Medicaid renewal (redetermination)Medicare & Medicaid
- The periodic review of whether a person still qualifies for Medicaid; missed notices are a common cause of coverage loss.
- Medical debtBilling & claims
- Unpaid medical bills owed to a provider or collector; subject to special credit-reporting and collection rules.
- Medical necessityInsurance & coverage
- The standard a plan uses to decide whether a service is needed to diagnose or treat a condition; the basis of many denials.
- Medicare Advantage (Part C)Medicare & Medicaid
- Private plans approved by Medicare that replace Original Medicare, usually with networks and prior authorization rules.
- Medicare Part DMedicare & Medicaid
- Prescription drug coverage offered through private plans approved by Medicare.
- Medicare Savings ProgramsMedicare & Medicaid
- State programs that help pay Medicare premiums and sometimes cost-sharing for people with limited income.
- Medicare Summary Notice (MSN)Medicare & Medicaid
- The quarterly statement for Original Medicare showing services billed and what Medicare paid.
- MedigapMedicare & Medicaid
- Private supplemental insurance that helps pay Original Medicare's cost-sharing; not used with Medicare Advantage.
- Minimum necessaryRecords & privacy
- The HIPAA principle of using or sharing only the least PHI needed for the purpose.
N
- No Surprises ActBilling & claims
- A federal law that protects patients from most surprise out-of-network bills for emergency care and certain in-network facility care.
O
- Observation statusMedicare & Medicaid
- Outpatient hospital status that can raise costs and affect Medicare coverage of later skilled-nursing care.
- Original MedicareMedicare & Medicaid
- The federal fee-for-service program: Part A (hospital) and Part B (medical), with any provider that accepts Medicare.
- Out-of-pocket maximumInsurance & coverage
- The most a patient pays for covered in-network care in a plan year; after that, the plan pays 100% of covered costs.
P
- Peer-to-peer reviewAppeals & rights
- A conversation between the treating clinician and the plan's medical reviewer about a denial.
- POLST / MOLSTCare & practice
- A medical order for people with serious illness that states treatment wishes for emergencies.
- PremiumInsurance & coverage
- The amount paid, usually monthly, to keep a health plan active, whether or not care is used.
- Price transparencyBilling & claims
- Federal rules requiring hospitals and plans to publish prices for items and services.
- Prior authorizationInsurance & coverage
- Approval a plan requires before certain services, procedures or drugs are covered.
- Protected health information (PHI)Records & privacy
- Individually identifiable health information held or sent by a HIPAA covered entity or business associate.
R
- ReferralInsurance & coverage
- Written approval from a primary care provider that some plans require before a patient sees a specialist.
- Revenue codeBilling & claims
- A hospital billing code identifying the department or type of service, such as pharmacy or room and board.
- Right of accessRecords & privacy
- A patient's HIPAA right to see and get copies of their health records, generally within 30 days.
S
- Scope of practiceCare & practice
- The services an advocate may offer given their training, credentials and the law, such as not giving legal or medical advice.
- Self-funded planInsurance & coverage
- An employer plan where the employer pays claims directly, often with an insurer only administering it. Determines which appeal and complaint rules apply.
- Special Enrollment PeriodInsurance & coverage
- A window outside open enrollment to get or change coverage after a qualifying event such as losing coverage, moving or having a baby.
- State insurance departmentAppeals & rights
- The state agency that regulates fully insured plans and accepts consumer complaints.
- Step therapyInsurance & coverage
- A plan rule requiring a patient to try a lower-cost drug before the plan covers the one prescribed.
Download the glossary
A branded 67-term PDF, organized by topic, to keep on hand or share with clients.