Glossary

A form signed by the patient before certain services are rendered, notifying him/her that Medicare or Medicaid may not cover this service and that the patient will be responsible for payment.

Process by which a request for a review of an insurance plan’s decision to pay, or the amount they paid for the purpose of reconsideration by the insurance company to pay a higher amount.

Portion of a bill, as defined by an insurance company, that remains unpaid and is owed by the patient.

Also called certification number or prior-authorization number; a number referencing that services have been approved by the insurance plan.

Amount billed for services provided.

CHAMPUS

Insurance provided to military personnel, also known as TriCare.

An itemized bill that is submitted to an insurance company for processing and payment for medical testing rendered by Athena Diagnostics.

The cost sharing portion of a bill that is paid by the policy holder.

Non-government insurance provider such as Blue Cross Blue Shield PPO or POS plans, Aetna, Cigna, UnitedHealth, etc.  Medicare, Medicaid and any other government managed insurance plans are not considered commercial insurance.

The amount paid by a policy holder each time a service is provided.

Current Procedural Terminology, an accepted method developed by the American Medical Association in connection with the Health Care Financing Administration Common Procedure Coding System to describe a medical service by use of a numeric code. This has been established as the standard code set for reporting health care services in electronic transactions.

The amount of a claim that the insured must pay before the insurance company will cover the rest.

Person or medical institution that provides medical services.

Health Insurance Portability and Accountability Act; a federal act which set standards for protecting the privacy of patient health information.

Diagnosis code used when filing insurance claims. This code must be provided by the physician.

Term used to describe the status of a healthcare provider with whom the insurance company has a contract to pay benefits.

An agreement entered into between Athena and a non-contracted commercial insurance provider to pay for testing.  Agreement is entered into prior to testing.

A state administered and funded insurance plan for low-income individuals who have limited or no other insurance.

A government administered and funded insurance program for individuals over the age of 65.

The group of physicians, hospitals, and other medical care professionals that a managed care plan has contracted with to deliver medical services to its members.

Charges for medical services which are denied or excluded by an insurance plan.

Term used to describe the status of a healthcare provider with which no insurance contract exists.  A provider which is not part of an insurance plan’s network of contracted providers. 

Money which may be owed by a patient and will not be paid for by insurance.

A healthcare option that allows members to choose at the time medical services are needed whether they will go to a provider within the plan's network or seek medical care outside the network.

See prior-authorization.

See prior-authorization.

Also known as pre-authorization or pre-certification; A utilization management technique that requires a plan member or the physician in charge of the member's care to notify the plan, in advance, of plans for a patient to undergo a course of care such as a hospital admission or complex diagnostic test. Also known as prior authorization.

Payment made by an insurance company to a healthcare provider.