Insurance Definitions

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ABC (Alternative Billing Codes)

Based on Complimentary and Alternative Medicine maintained by Alternative Link.

Congenital

A disease or disorder that is a result of genetic abnormalities, the intrauterine (uterus) environment, errors of morphogenesis, a chromosomal abnormality, or a complex mix and unknown factors. Some factors can include heredity, environmental, or behavioral. Congenital disorders vary widely in causation and abnormalities. Insurers see this as “untreatable”.

CPT (Code of Procedural Terminology 4th Edition)

One of the two National Standards for determination of services for diagnosis, under HIPAA. You can purchase a CPT Catalog from the American Medical Association or other bookstore.

EPSDT (Early Periodic Screening, Diagnosis and Treatment)

Minimum standard of care for Medicaid services.

ERISA (Employee Retirement Income Security Act)

ERISA is a federal law that sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in these plans.

EOB (Explanation of Benefits)

The EOB is a document sent to you every single time someone bills your insurance company for a treatment or visit.  It tells you who is billing; for what service; for what dates; how much the insurance company paid, or didn’t pay; and if you owe the provider anything after the insurance company paid. Don’t throw these away, ever.

HCBS (Home Community Based Services Waiver)

This is a program to provide treatment, habilitative therapy, habilitative training, respite and supports for individuals with disabilities, specifically developmental disabilities.

HCPCS (Healthcare Common Procedure Coding System)

This coding is used for Government entitlements such as Medicaid and Medicare, etc. and is accepted by some Insurance Companies under HIPPA.

Health Insurance Plan Types

  • HMO-Health Maintenance Organization (least flexibility in coverage and providers)
  • PPO-Preferred Provider Organization (best plan option)
  • POS-Point of Service Option (limited options but better than HMO)

(TIP: If you are currently in the HMO plan, ask your employer when the open enrollment period is so you can change to the PPO.)

HSA (Health Savings Account)

A Health Savings Account is a savings account into which you can deposit money on a tax-preferred basis. HSA funds can pay for any “qualified medical expense”, even if the expense is not covered by your HDHP. For example, most health insurance does not cover the cost of over-the-counter medicines, but HSAs can.  If the money from the HSA is used for qualified medical expenses, then the money spent is tax-free. More details of this are on 

 

HIPPA (Health Insurance Privacy & Portability Act/Health Information Portability Accountability Act)

HIPPA establishes National Standard Procedure Codes for “covered entities” and includes privacy provisions for electronically transferred information.  HIPPA establishes that National Standards supersede Local Coding standards.

ICD9 (International Statistical Classification of Diseases and Related Health Problems 9th & 10th edition)

Adopted under HIPPA as National Standard for Classification

NCHS - National Center for Health Statistics under the CDC

NCVHS - The National Committee of Vital Health Statistics is convened under the Center for Disease Control and Prevention.

NDC (National Drug Code)

NDC Directory is limited to prescription drugs and insulin products that have been manufactured, prepared, propagated, compounded, or processed by registered establishments for commercial distribution.

Superbill

This is the paper that says what services were provided, when, to whom, by whom, and contains the appropriate billing (CPT) and diagnosis (ICD9) codes your insurance company will need to process payment.  Usually these are only provided by physicians, not therapists.  Therapists just provide invoices or statements normally. Example of a Superbill.

Tricare (Military Insurance)

 

See our definitive collection of abbreviations and definitions.