A - B - C - D - E - F - G - H - I - J - K - L - M - N - O - P - Q - R - S - T - U - V - W - X - Y - Z

A 

Advocate
A person who gives you support, protects your rights, and/or works on your behalf.

Allowable
The amount of money for which a third party payer will allow a claim to be processed. Often co-payments are based on allowable amount, not necessarily the manufacturer's invoice amount.

Appeal
An appeal is a formal complaint made when there is a disagreement with any decision made about your health care services. For example, you would file an appeal if your insurance company refuses to authorize equipment that has been deemed medically necessary for you, and is covered under your policy.

Assignment of Benefits (AOB)
Form signed by the policy holder that allows the third party payer to pay the provider directly. Without an AOB, payment might be sent to the policy holder.

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B

Beneficiary
The formal name of the person who has health insurance through Medicare, Medicaid, and/or Insurance.

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C

Centers for Medicare & Medicaid Services (CMS)
The federal agency that runs the Medicare program. In addition, CMS works with the states to run the Medicaid program. CMS works to make sure that the beneficiaries in these programs are able to get high quality health care.

Certificate of Medical Necessity (CMN)
This state-specific form must be completed by the doctor and/or speech therapist. In most cases, the CMN is in lieu of a prescription and must be signed by a physician.

Claim
Billing form submitted to the third party payer following delivery of services or products to the client.

Coinsurance
The percent of the approved amount that the client pays after the deductible is paid.

Confidentiality
Your right to communicate with your provider without anyone else finding out what is said.

Cost Sharing
The cost for medical care that is paid by the client such as a co-payment, coinsurance or deductible.

Covered Benefit
A health service or item that is included in your health plan, and that is paid either fully or partially.

CPT Code
Current Procedural Terminology. The code that describes the type of services/equipment being supplied. This is the same as HCPC code.

Custodial Care Facility
Facility that provides room, board and assistance with activities such as feeding and dressing. This care is generally on a long term basis and might entail the continuing attention of trained medical personnel.

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D

Deductible
The amount the client must pay yearly before a third party payer begins to pay.

Denial
A notice received following a request for pre-certification/prior authorization from a third party payer. The notice reflects the reviewers findings that the equipment prescribed is either/or found to be not medically necessary, or not covered by the policy. The reason for the denial is stated within the documentation, and is sometimes successfully reversed through an appeal process.

Diagnosis
The identification of the client's health condition. Diagnosis is reflected by an ICD-9 code, which is an industry-wide code used to describe a client's medical condition.

Dual Eligible
Persons who are entitled to more than one source of third party reimbursement. For example, a client covered by both Medicare and Medicaid is dual eligible.

Durable Medical Equipment
Medical equipment that is ordered by a doctor for use in the home, and will withstand repeated use. Prentke Romich's speech generating devices have been classified as Durable Medical Equipment.

Durable Medical Equipment Regional Carrier (DMERC)
A private company that contracts with Medicare to pay bills for durable medical equipment. There are four separate regions in the United States.

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E

Explanation of Benefits (EOB)/Explanation of Medicare Benefits (EOMB)
A notice that is sent after a claim form is reviewed by the third party payer. This notice explains the amount billed by the provider, the approved amount, how much was paid, and what, if anything, the client owes.

Exclusions
Products and services for which the third party payer will not pay.

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F

Fee Schedule
A complete listing of fees used by health plans to pay doctors and other providers.

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H

Health Insurance Portability & Accountability Act (HIPAA)
A law passed in 1996 which was designed to expand health care coverage for those that lose a job, or need to move from one job to another. HIPAA protects clients who have pre-existing medical conditions and/or those having difficulty getting medical coverage. HIPAA also mandates providers keep your health information secure and private, and establishes uniform coding throughout the industry in attempt to reduce medical expenses derived from administrative processes.

Hospice
A special way of caring for people who are terminally ill, and for their families. The care includes physical care and counseling.

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M

Maximum Out of Pocket
The maximum amount a client will pay toward their deductible and/or co-insurance during the year.

Managed Care Organization (MCO)
Any insurance plan in which the client will need to have services approved by their plan's referring physician or medical group.

Medicaid
A joint federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state.

Medical Release
Written permission from the client and/or guardian to share private health information regarding the client with others. Written permission is not required when a provider shares information with those identified as part of the client's team, and with third party payers.

Medically Necessary
Services or supplies that: are proper and needed for the diagnosis, or treatment of the client's medical condition; are provided for the diagnosis, direct care, and treatment of the client's medical condition, meet the standards of good medical practice in the local area; and are not mainly for the convenience of the client or doctor.

Medicare
The federal health insurance program for individuals over the age of 65 or younger that have a qualifying disability.

Medicare Supplemental Plan
A policy that is purchased by the Medicare beneficiary to cover any Medicare co-payment(s).

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N

Non-participating Provider
Provider that has not contracted with a health insurance company to provide services at a reduced fee. Also referred to as an out of network provider.

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O

Original Documentation
Prescription and speech evaluation that has an original signature. The signature page on the evaluation and the doctor's prescription cannot be copied or faxed. Medicare requires that original documentation be on file with the provider.

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P

Part B Medicare
Medicare medical insurance that helps pay for doctor's services, outpatient hospital care, durable medical equipment (including speech generating devices), and some medical services that are not covered by part A. Clients must pay a monthly fee for Part B coverage.

Pended Notice
A notice received following a request for pre-certification/prior authorization from a third party payer. The notice identifies missing information in the documentation, which without, cannot prove medical necessity. Generally, failure to return the missing information within a specified time frame may result in a denial.

Place of Service
The location where the medical services will be provided to the client. Coverage can depend on whether the client resides at home, in a group home, or in a nursing facility. Clients residing in a Skilled Nursing Facility or Hospice are usually not eligible for speech generating devices with certain third party payers.

Pre-certification, Prior Authorization
Approval issued by a third party payer before the equipment is provided. The process usually entails completion of state forms and the attachment of documentation to prove medical necessity.

Pre-determination
A medical review done by an insurance company to determine whether the service can be considered a covered benefit.

Primary Care Physician (PCP)
The primary care physician is the physician the client sees first for most health problems. The PCP might refer the client to other specialists, and must be seen before any other physician is visited.

Provider
A doctor, hospital, health care professional, health care facility, or manufacturer of medical equipment.

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S

Sole Provider
A provider who is the only source for equipment or services. Prentke Romich Company (PRC) is the sole provider the Pathfinder and all other PRC speech generating devices. Many insurance companies will reimburse a greater amount when informed that PRC is the sole provider.

Subscriber
The person covered under an employer's insurance policy. This person is identified as the policy holder.

Skilled Nursing Facility (SNF)
A nursing facility with the staff and equipment to give skilled nursing care and/or skilled rehabilitation services and other related health services. In general, clients residing in a SNF do not qualify to receive benefits for speech generating devices under Medicare.

Speech Generating Devices (SGD)
The classification in which Medicare has placed augmentative communication devices such as those manufactured by Prentke Romich.

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T

Tricare
TRICARE is the health care program for active duty members of the military, military retirees, and their eligible dependents. TRICARE was called CHAMPUS in the past.

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U

UPIN
Unique Physician Identification Number. Identification number that is used to identify the physical who wrote the prescription. This number is required by various third party payers.

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W

Waiver of Liability (WOL) /Advance Beneficiary Notice (ABN)
A notice that a provider should give a client to sign in the following cases: The provider believes the services prescribed are not considered medically necessary; and the provider gives you a service that is believed to be not payable by a third party payer. When a signed WOL has not been obtained by a provider in advance, the client is not liable for any expenses not covered by Medicare which are deemed to be not medically necessary.

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