OHSU

Glossary

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Adjustment /Discount
The portion of your bill that is adjusted in accordance to the contract between OHSU and your insurance company.

Amount Not Covered
The amount your insurance company will not pay, for example: deductibles, co-insurance, co-payments and other charges for services determined to be non covered as part of you benefit package.

Applied to Deductible
The portion of your bill, as agreed with your insurance company, that you owe your medical provider.

Authorization Number
A number your insurance company issues that indicates your treatment has been approved.

Benefit
The services that are covered under your insurance plan.

Bill/Statement
A printed summary of the medical services you received.

Claim
The bill for your services that the hospital and/or physician sends to your insurance company for payment.

Co-insurance
The portion of your covered services that your insurance company requires you to pay after meeting your deductable.

Coordination of Benefits (COB)
Rules that that help determine the primary insurance company in situations where an insured is covered by more than one policy.

Co-payment
A set fee established by your insurance company for a specific type of visit.

Covered Services
A health care service your insurance company agrees to pay a pre-established rate and/or percentage for.

Date of Service (DOS)
The date you were provided healthcare services.

Deductible
The amount you must pay on an annual basis.  This amount is established by the insurance company.

Explanation of Benefits (EOB)
The notice you receive from your insurance company explaining how your claim was processed and/or paid.  It will indicate the amount billed, paid, denied, discounted, not covered, and the amount owed by the patient.

Hospital Charge
The amount of money the hospital charges for a specific medical service and/or supply.

Inpatient (IP)
A patient is an inpatient when the physician orders an “inpatient admission”.

Insured’s Name (Beneficiary)
The name of the insured person.

Non-Covered Charges
Services not covered under the patient’s insurance plan.  These charges are the guarantor’s responsibility to pay.

Out-of-Network
Services rendered by a provider which does not have a contract to offer you care.  Typically, managed care plans are contracted whit a panel of providers.  If a patient sees care out-of-network, they may be financially responsible for some or all of the care provided.  An exception to this rule is emergency medical care.

Out-of-Pocket Costs
The amount that is paid by the patient or guarantor.

Out-of-Pocket Maximum
The maximum yearly amount that is paid by the patient or guarantor.

Outpatient (OP)
A treatment or service you receive that does not require hospitalization.

Outpatient Hospital Departments
Outpatient hospital departments are those that meet the same higher standards for physical setting and patient care as required for a hospital. OHSU's clinics--where we see our outpatients--are outpatient hospital departments.

Payment Arrangements

The monthly amount the patient or guarantor agrees to pay towards their outstanding bill.

Policy Number
A number your insurance company gives you to identify you and/or your coverage.

Pre-Certification Number
This number represents the agreement by the insurance company that the services has been approved.  This is not a guarantee of payment.

Pre-Existing Condition
A health condition or a medical problem acknowledged by your insurance company as not covered as a benefit.

Primary Care Physician (PCP)
The primary care physician is responsible for all general medical care of the patients and referrals to specialists for care when medically appropriate.

Primary Insurance Company
The insurance company responsible for paying your claim first.

Prior Authorization/Pre-certification
A formal approval obtained from the insurance company prior to the delivery of medical services.

Provider
A hospital or physician who provides medical care to the patient.

Provider-Based Billing

Provider-based billing is another name for how OHSU bills for our hospital-designated clinics (see definition above). In brief, it's way that federal payers like Medicare use to recognize the higher standard of care provided in clinics like those at OHSU.

Reasonable and Customary (R&C)
The cost for medical services that insurance companies believe are appropriate throughout the geographic area or community. OHSU is under no obligation to accept this amount unless we are under contract to do so.

Referral
Approval or consent by a primary care doctor for a patient to see a certain specialist or receive certain services.

Responsible Party/Guarantor
The person responsible to pay the bill.

Secondary Insurance
The insurance company responsible for paying the balance of your claim after the primary insurance company has determined benefits.

Subscriber
The person who is enrolled for benefits with an insurance company.

Total Charges
The total price of your medical services.

Usual and Customary (U&C)
The cost for medical services that insurance companies believe are appropriate throughout the geographic area or community.

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