Glossary & Reference Library

270
Eligibility benefit inquiry. Transaction allows the provider to submit patient's known information (e.g., Member ID, DOB) for identification.

271
Eligibility benefit inquiry response

276
Healthcare claim status request

277
Healthcare claim status response

5010
ASC X12 Version 5010. New standard format for electronic claims and claims-related transactions.

835
ANSI ASC X12 Claim Payment/Remittance Advice, the national standard format for claim payments to providers, mandated by HIPAA. Includes the payer, payee, amount, and identifying information about the payment. See EOP.

837
Healthcare claim or encounter; electronic claim submitted to a payer for payment

Above-the-Line Deduction
HSA contributions made directly from a paycheck (before taxes are calculated and paid).

Accountholder
The person or entity responsible for a credit or debit account

Accreditation
A term applied to hospitals and other health care facilities or a health benefits plan indicating that the facility or plan has met operating, quality, and other standards established by a third-party review agency.

ACH
Automated Clearinghouse

Adjudication
The determination of a health plan participant’s financial responsibility after a medical claim is applied to his or her insurance benefits.

Administrator, Program
The entity that manages the administrative services of a benefit-spending program. U.S. Bank is one of the nation's leading HSA administrators.

Administrator, Third Party
An independent entity that manages business functions for an employer. May adjudicate and pay claims on behalf of a payer.

ANSI X12
A protocol from the American National Standards Institute (ANSI) for electronic data interchange (EDI). Also known as "X12" and "ASC X12."

APR
Annual Percentage Rate (APR)

Automated Clearinghouse (ACH)
A nationwide network that allows electronic funds transfers -- such as claim payments -- between banks.

Beneficiary
An individual (or individuals) selected to inherit or be the successor owner of any HSA funds that remain in the HSA account after death.

Broker
An agent who matches clients with goods and services that meet their business needs.

Catch-up Contributions
Additional contributions above those listed as the annual contribution limits, available to HSA owners beginning in the year they reach age 55.

CDH
Consumer-Directed Healthcare. Also Consumer-Driven Healthcare.

Claim
A bill for healthcare services that is submitted to the insurance company for payment. Used to determine whether and what amount of benefits should be applied for services rendered.

Claim Status Inquiry
An inquiry to validate and track the status of a claim after it has been submitted to a payer.

Co-Insurance
A provision within health plan coverage whereby the insured shares in the cost of covered services on a percentage basis. The health plan pays a certain percentage of the cost while the covered person pays the remainder.

Co-Payment
A fixed charge that an insurance plan participant pays for services received. Example: A fee collected at the time of a visit to a physician’s office or the emergency room.

Concierge Medicine
Enhanced access to care for a flat yearly fee. Services may include guaranteed same-day appointments, access to doctors via their cell-phone numbers, quick consults with specialists, and more.

Consumer-Directed Health Care (CDHC)
A term that refers to health plans in which employees have a personal health account, such as a Health Savings Account (HSA) and/or a Health Reimbursement Account (HRA), from which they pay medical expenses directly.

Consumer-Directed Health Plans (CDHP)
A system of healthcare that gives individuals more direct control over their medical expenses. Characterized by health plans with lower premium costs in exchange for higher deductibles.

Consumer-Directed Healthcare (CDH)
A suite of benefit spending accounts – like HSAs, FSAs, and HRAs – that help employees save and pay for certain expenses, such as healthcare, daycare, parking, and transit. Our solution includes a “multi-purse” payment card and an easy-to-use account-management site.

Consumers
Health plan and/or spending account participants; usually employees.

Covered Expenses
Services for which the health plan makes either a full or partial payment.

Deductible
The amount of qualified expenses an insurance plan participant is required to pay before the health plan assumes part or all of the costs.

Defined Contribution
In lieu of a traditional benefits package, an employee receives money from his employer to purchase a health plan on his own through a health insurance exchange

Dependent Care Reimbursement Account
Spending account that allows reimbursement of dependent care expenses (e.g., daycare) incurred by eligible dependents.

eCheck
An exchange of funds in which money is electronically transferred from the bank account of one party into the bank account of the other party via a checking account routing number and an account number.

EDI
Electronic Data Interchange; a set of standards for formatting information that will be shared electronically between groups.

EFT
Electronic Funds Transfer

EHNAC
Electronic HealthCare Network and Accreditation Commission

Electronic Data Interchange (EDI)
A set of standards for formatting information that will be shared electronically between groups.

Electronic Funds Transfer (EFT)
An arrangement in which providers may deduct funds electronically from a patient’s account and deposit claim payments from a payer.

Electronic HealthCare Network Accreditation Commission (EHNAC)
Entity that establishes criteria for measuring performance of clearinghouses and value-added networks.

Electronic Remittance Advice (ERA)
An electronic version of an Explanation of Payment (EOP).

Eligibility
The process for verifying a patient's insurance coverage.

Eligibility Benefit Inquiry
Eligibility Verification

Eligibility Verification
An electronic inquiry to obtain information regarding a patient’s health insurance benefits. See 270/271.

EOB
Explanation of Benefits

EOP
Explanation of Payment

ERA
Electronic Remittance Advice

Estimation
The process for determining what the patient must pay out of pocket for a specific healthcare service and what the insurer will owe.

Explanation of Benefits (EOB)
A summary of how an insurance company has processed a medical insurance claim. Details what the payer has paid to the provider and what is owed by the patient.

Explanation of Payment (EOP)
A document or electronic message that details how an insurance company or other payer has processed a claim. See 835.

Family Coverage
Any coverage specified for more than one individual (self-only coverage).

First-Dollar Coverage
Immediate reimbursement or no payment required for specific covered expenses, without meeting a deductible. Some preventative services may have first-dollar coverage under the terms of the health plan and still qualify for an HSA-eligible plan.

Flexible Spending Account (FSA)
Employee-funded savings account that allows participants to set aside a portion of their earnings to pay for qualified expenses, including medical, dependent care, and other expenses. The total annual election amount is available on Day 1. Most FSA balances do not roll over and are forfeited if unused.

Float
The amount of time between when a transaction occurs and when it is posted to an account.

FSA
Flexible Spending Account

Guarantor
The person or entity responsible for payment.

HDHP
High-Deductible Health Plan; often paired with an HSA.

Health Insurance Exchange
A virtual "insurance mega-mall" where participants can shop for a health plan, compare benefits and prices, and choose the plan that’s best for them

Health Insurance Portability and Accountability Act (HIPAA)
Federal legislation enacted in 1996. Title II standardizes healthcare-related information systems -- specifically, the exchange, security, and confidentiality of healthcare-related data.

Health Plan
A health insurance policy

Health Reimbursement Accounts (HRA)
A partially self-funded account in which an employer pays a predetermined portion of medical claims up to a cap.

Health Reimbursement Arrangement (HRA)
An employer-funded, tax-sheltered arrangement that helps participants pay for qualified medical expenses not paid by the health plan.

Healthcare Consumerism
The deliberate and well-considered participation of consumers in their healthcare buying experiences, resulting in the proper balance between healthy outcomes and reduced costs

Healthcare Creditline
An affordable line of credit that providers can offer patients to help them pay for medical expenses.

Healthcare Payment Solutions
A suite of products from U.S. Bank for anyone who makes, receives, or orchestrates a healthcare payment.

Healthcare Reform
Legislation that seeks to improve interactions with health insurers, reduce costs, create means for more consumers to secure insurance coverage, and safeguard plan participants from predatory insurance practices.

HFMA
Healthcare Financial Management Association

High Deductible Health Plan (HDHP)
A health benefit plan that typically offers lower premiums in exchange for higher annual deductibles when compared to traditional health plans.

HIPAA
The Health Insurance Portability and Accountability Act of 1996, mandating electronic claim payments

HIS
Hospital Information System

Hospital Information System (HIS)
The collection, evaluation, storage and retrieval of information about a patient.

HRA
Health Reimbursement Account; Health Reimbursement Arrangement

HSA
Health Savings Account

HSA Credit Account
A line of credit for HSA participants that can be used to pay for qualified medical expenses when HSA funds have been depleted.

ICD-10 CM/PCS
International Classification of Diseases, Clinical Modification/Procedure Coding System. First major update in 30 years. Compliance date for the new classification system is 10/1/13.

Intelligent Optical Character Reader
Technology for scanning documents and turning them into text that can be edited, archived, and shared.

IOCR
Intelligent Optical Character Reader

Issuer
The financial institution that issues or causes to be issued a credit or debit card.

Limited-Purpose FSA (LPFSA)
A benefit spending account that coordinates with a qualified High Deductible Health Plan (HDHP) and Health Savings Account (HSA). Allows reimbursement for preventive care, vision and dental expenses only.

Line of Credit
An open-ended, revolving loan which a borrower may access up to his or her limit.

LPFSA
Limited-Purpose Flexible Spending Account

Maximum Annual Contribution
The total amount the government and applicable law allows an accountholder to add to his or her HSA in a given year.

Medical FSA
A benefit spending account that allows reimbursement of qualifying out-of-pocket medical expenses.

Medical Savings Account (MSA)
The precursor to HSAs, these were tax-exempt trust or custodial accounts in which accountholders could save money for future qualified medical expenses.

Member
Health plan participant

Multi-Purse
The ability to access more than one type of spending account on a single payment card.

NACHA
The Electronic Payments Association; previously known as the National Automated Clearing House Association

Optical Character Recognition (OCR)
The mechanical or electronic translation of scanned images into machine-encoded text.

Out-of-Pocket Maximum
A cap that contains or limits the dollar amount an insured must pay in coinsurance, deductibles and co-payments. After the out-of-pocket maximum is reached, additional covered healthcare expenses are paid in full by the health plan.

Patient
The consumer of healthcare services; may be separate from the guarantor.

Patient Estimator with Automated Payment
Calculates a patient’s out-of-pocket responsibility for co-pays, co-insurance and deductibles specific to the services being provided and the service provider’s contract with the patient’s health plan.

Patient Financing
A line of credit offered to patients by providers to pay for expenses related to a medical event.

Patient Payment Portal
Web-based service that allows patients to pay online with credit, debit, eCheck or benefit-spending account (HSA, FSA or HRA).

Patient-Centered Medical Home
A care model in which each person has a personal physician who serves as the point of first contact and coordinates care across multiple settings.

Payer
The entity that adjudicates and pays claims. This could be a self-insured employer, a health plan, an HMO, a PPO, a government agency, and/or a plan administrator.

Payment Accelerator
A complimentary Web service for providers whose payer partners use Payment Master. Enables users to receive ERA/EFT and other electronic healthcare transactions from health plans.

Payment Assurance
A pledge that a product or service will help patients to pay and providers to collect on services rendered.

Payment Consolidator
An online service that enables providers to receive, post, and reconcile health-plan claim payments and remittances electronically.

Payment Consolidator Lite
Service that allows users to view EOB images through an easy-to-use portal.

Payment Master
An outsourced claims settlement solution for payers that streamlines the payment of health insurance claims to healthcare providers.

Payment Navigator
Web-based, HFMA peer-reviewed tool that simplifies eligibility, estimation, payment, and reporting.

PCI
Payment Card Industry Data Security Standard (PCI DSS), a set of requirements designed to ensure that all companies that process, store, or transmit credit-card information maintain a secure environment.

PCI Level One
Characterizes a Payment Card Industry Data Security standard. Applies to any merchant processing over 6M Visa transactions per year.

Peer Review
The evaluation of information, a product, or a service by subject-matter experts. Payment Navigator has been peer reviewed by the Healthcare Financial Management Association.

Permitted Insurance
Insurance that may be held while an individual contributes to an HSA includes insurance for a specified disease or illness, such as cancer, diabetes, asthma or congestive heart failure. Other examples of permitted insurances: policies that provide coverage for workers compensation, accidents, disability, dental care, vision care or long-term care.

Practice Management System (PMS)
Software that handles the day-to-day operations of a medical practice, such as capturing patient demographics, scheduling appointments, maintaining lists of health plan payers, performing billing tasks, and generating reports.

Preferred Provider Organization (PPO)
A health care delivery arrangement that offers insured individuals access to participating providers at reduced costs. Traditionally, PPOs encourage enrollees to use providers in their network by offering lower deductibles and co-payments.

Preventative Care
Healthcare services intended to prevent a medical condition from occurring or to detect early onset so that it could be treated more effectively.

Provider
Any entity that delivers professional healthcare services. This includes health systems, hospitals, clinics, and individual healthcare practices.

Qualified Medical Expenses
Medical expenses permitted to count toward an individual satisfying their health plan deductible. Visit www.mycdh.usbank.com for details.

Remittance
A payment sent for medical services provided to a patient. See Electronic Remittance Advice.

Remittance Advice
A type of receipt given to providers that details claims payments, including whether a claim has been denied.

Remote Deposit
The ability to deposit a check into a bank account without having to physically deliver a paper check to the bank.

Revenue Cycle
The series of activities from the time the patient makes an appointment or arrives at the facility until the provider has been paid in full.

Swipe Device
A check reader or a other machine that reads the magnetic strip on the back of a payment card.

Tax-Free Contributions
A program through the employer that allows deductions to be taken from payroll before calculating the plan participant's taxable federal income, Social Security, and for most states, taxable state income.

Third Party Administrator (TPA)
An independent entity that processes healthcare claims or manages certain aspects of an employee benefits program for an employer.

TPA
Third-party administrator

WEDI
Workgroup for Electronic Data Interchange

Workgroup for Electronic Data Interchange (WEDI)
An organization that identifies strategies for reducing administrative costs in healthcare through the implementation of electronic data interchange.

X12
An ANSI-accredited group that defines EDI standards for many American industries, including healthcare. Most of the electronic transaction standards proposed under HIPAA are X12 standards.