Medical Billing Terms

1. WHAT IS MEDICAL BILLING?

It is the process by which charges are applied for medical services rendered by a provider, to be paid
by health plan insurers.

2. WHAT IS AN INVOICE?

It is a document that reflects the provision of a medical service, which includes the information of the patient, the information of the insured of the medical plan, the date of service, the procedure and the charges that apply for the provision of the same, so that later , this is processed and paid in full to the provider that provided said
service.

Medical billing companies

3. WHAT IS ELECTRONIC BILLING?

It is the process by which invoices are registered and issued. These are sent electronically and are
processed more efficiently and in less time than paper invoices.

4. WHAT IS COMPUTERIZED BILLING?

It is one where a computer is used to carry out the billing process.

5. WHAT IS A BILLER? 

It is the person in charge of preparing and processing the invoices for the services provided to different medical plans, who can invoice them electronically or manually. 

6. WHAT IS A COLLECTION?

It is the procedure that follows after completing the billing process, and which is obtained once
the invoice has been corroborated and has received the approval for said payment to be made.

7. COVERAGE – It is the word used to indicate all the benefits included in the health care plan for the insured and beneficiaries of the same.

8. DEDUCTIBLE – Established fixed amount paid by the patient for services received annually. 

9. PATIENT – It is the person who goes to a provider and receives medical services for any cause or complaint related to illness, condition, injury or accident.

10. INSURED – It is the person who appears as the main insured in the Medical Plan and who in the case of a family-type policy represents the family unit before the plan.

11. BENEFICIARY – Person eligible to receive benefits under a health insurance policy. 

12. INTERMEDIARY – It is the company that subscribes and / or administers a health insurance policy or plan.

13. INSURANCE COMPANY – It is the company that represents a medical plan and where you can call or go if you need any help regarding the medical plan.

14. PREMIUM – Amount of money that you pay each month to receive insurance coverage.

15. SECONDARY PLAN – Covers the difference of what is not covered by the primary plan.

16. CO-PAYMENT – Refers to payment for services based on fixed prices.

17. CO-INSURANCE – Refers to payment for services based on percentage ($).

18. MEDICAL INSURANCE – Financial plan that covers the cost of hospitalization and medical care for illness or injury.

19. PROVIDER – It is an organization or health professional authorized to provide services to subscribers or policyholders of a Health Insurance plan. 

20. HEALTH PROFESSIONAL – Is that person who is permitted and / or authorized to perform a medical health service in Puerto Rico under the applicable laws and regulations.

21. PRE-AUTHORIZATION – Prior authorization issued by the business plan that authorizes receiving services.

22. DIAGNOSIS – Illness or condition that, after performing the diagnostic tests, is established as the cause of the need for the service.

23. SERVICE CODES – Codes that identify the coverage to which the insured and / or the participants of the contract are entitled. These codes are identified on the medical plan card.

24. CLAIM – Process by which a health insurance company is asked to charge for a medical service through manual or electronic documents.

25. PROFESSIONAL MANAGEMENT – Procedures and requirements between the Medical Services Provider and the Health Insurance Company that includes: handling of documentation, assigning passwords, requesting authorization, endorsements and other procedures related to Medical Services Billing.

26. MEDICAL BILL ANALYSIS – Medical bill evaluations for the purpose of reconciling, re-billing, error identification, medical review, utilization, reporting, and others.

27. AMBULATORY SURGERY – Procedure to which a patient is submitted, where it is performed without the need for hospitalization.

28. PRE-ADMISSION – Guidance provided to the patient regarding the documents required for the billing process. Among them are: medical orders for admission or treatment, card of the medical plan or plans that you have and authorization of the medical plans that require it.

29. ADMISSION – Process that is carried out once the patient is going to be admitted on the recommendation of his doctor for a surgical procedure.

30. CMS – Centers for Medicare and Medicaid Services / Centers for Medicare and Medicaid Services

31. FORM CMS-1500 – New form used by the biller to process outpatient medical services manually.

32. CPT – Book used to code procedures.

33. ICD-9-CM – Book used to code diagnoses.