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Guide to Common Healthcare Terms and Acronyms

Updated

Healthcare is full of complex terms and acronyms that can leave customers confused and unable to deliver the best results possible. Myndshft has compiled this guide to understand so on healthcare terms, descriptions of Myndshft's most common terminology have also been included. Myndshft-specific terms are highlighted in orange. 

General Medical Terms Acronyms & Abbreviations

Terminology

Explanation / Context
Benefits Verification & Eligibility A process of determining a patient's ability to pay for care. In connection with Benefits Verification, this will confirm who will pay and how much responsibility/cost each will assume for the patient's care. 
Coinsurance  Patient's portion of total covered healthcare costs after the deductible has been met. 
Coordination of Benefits Myndshft identifies other payers — even when they are not included as part of an eligibility verification request — and returns detailed information on the primary, secondary and tertiary payers as part of a consolidated response.
Copay Additional cost of a drug / therapy above and beyond the costs paid by the insurer.
Coverage Level

This is the amount of risk or liability that is covered for an individual or entity by way of insurance services. In exchange for insurance coverage, the insured person is responsible for paying premiums to the insurance company.
CPT Code

This is a medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies, and accreditation organizations.
Deductible

The dollar amount the Patient would pay for covered health care services before their insurance plan starts to pay.
Determination Status

This field in your Prior Authorization Determination Response displays if Prior Authorization is Required or Not Required.
Diagnosis Code

A combination of letters and/or numbers assigned to a particular diagnosis, symptom, or procedure. (See ICD-10 Codes)
EHR/EMR

(Electronic Health Record/Electronic Medical Record) This is confidential patient medical information that providers and healthcare resources store in electronic software. EHR is also used to describe the system which houses such data (Epic, Cerner, etc.).
Episode of Care

All the care a patient receives in the course of treatment for a specific illness, condition, or medical event.
Group

This is a sub-classification of a plan that has similar services, offerings, provider networks, and pricing. A group of members is usually comprised of company employees or members of an organization. Group health members usually receive insurance at a reduced cost because the insurer's risk is spread across a group of policyholders.
Group Name

Name of the group (usually and employer) or insurance plan that insures the patient.
Group Number

A number the insurance company uses to distinguish the group under which the Patient is insures. This number identifies the covered group such as an employer insurance plan. 
Guidelines

Insurance Payers use evidence-based guidelines to inform providers of patient coverage. The content of these guidelines relies on the same evidentiary base as clinical treatment guidelines, which promote effective health diagnoses and treatments for their members and ensure that members are not subject to harmful or wasteful care. 
ICD-10 Codes 

 A system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms and procedures recorded in conjunction with hospital care in the United States.
In Network

When a doctor, hospital, or other provider accepts your health insurance plan they are considered "in network." Patients are often referred to participating providers.
Insurance Discovery Myndshft Insurance Discovery uses intelligent algorithms to search patient specific information for more than 2,000 payers, clearinghouse databases, and direct connections infrastructure to accurately identify the active coverage and payer specific benefits for patients.
Insurance ID Number A Health Insurance ID Number is typically the same as the Member ID Number or Policy Number. This number is specific to the patient's health insurance company and can be used to find information regarding the patient's benefits and any recent claims.
Insurer The insurance company that provides the insurance cover.
Interoperability Is the ability for two or more systems to exchange health information and use the information once it is received. 
Managed Care A system of healthcare in which patients agree to visit only certain doctors and hospitals, and in which the cost of treatment is monitored by a managing company. This system is to reduce cost while maintaining a high quality of care.
Medicaid Insurance provided by the federal government and individual state governments for people with lower income. MedicAID (provide aid for the needy)
Medicare Insurance provided by the federal government for individuals based on their age (65+). MediCARE (care for the elderly)
Medicare Advantage A supplemental health insurance elderly people can opt into, which enhances their Medicare offerings. Usually comes with more medicines covered, more procedures covered, specialized services, etc. This is provided by the Payer, and can be purchased from the marketplace. 
Medicare Replacement Medicare coverage provided by a commercial payer in place of a standard Medicare plan. 
Myndview Myndshft's proprietary User Interface which enables performing Benefit Verification, Patient Financial Responsibility, Coordination of Benefits, Prior Auth Requirements Determination, and Prior Authorization Submissions. This application is completely web-based and requires no integration.
Network Description This field in Myndview displays the Patient's Insurance Network identified by the Benefits Verification and Eligibility transaction.
Network ID This field in Myndview displays the Patients Network ID number that matches their Network of coverage.
NPI (National Provider Identifier) The NPI is a unique identification number for covered healthcare providers. Covered healthcare providers and all health plans and healthcare clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position
Ordering Provider This is the Care Provider who is requesting to submit a Prior Authorization before care can be provided.
Out of Network When a doctor, hospital, or other provider does not have a contract with your health insurance plan provider. This can sometimes result in higher prices for care to the patient. 
Out of Network Determination When a doctor, hospital, or other provider does not have a contract with your health insurance plan provider. This can sometimes result in higher prices for care to the patient. 
Out-of-Pocket Cost Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that aren't covered.
Prior Authorization Determination (PAD) This is a Myndshft product that enables providers to check payer guidelines and other requirements before a patient can receive particular procedures.
Patient Information This is specific PHI needed to check eligibility. (e.g., Name, Date of Birth, State, and Gender)
Patient Responsibility or Patient Financial Responsibility The cost of care paid by the patient before care is provided through per diems, coinsurance, copays, and out-of-pocket charges. (What the patient pays above and beyond the costs paid by the insurer (payers)).
Payer The entity that provides differing health insurance options to its members, and works on behalf of the patient to advocate for better health outcomes. They have several plans underneath them that are customized based on the patient population they are serving. A couple examples include traditional PPO, Medicare, Medicaid etc. 
Per diem By the day (daily) "Per day." Per diem is also a cost associated with patient care paid by the patient each day he/she receives therapy. 
PFR (Patient Financial Responsibility) Myndshft's patient financial responsibility calculation is exactly that, a calculation. Unlike many competitors who provider estimations based on location and CPT code, Myndshft uses the customers' contracted rates and the exact patient benefits to calculate the patient's overall total coast for their services.
Pharmacy Benefits Manager Health plans will help pay the cost of certain prescription medications. Patients may be able to buy other medications, but medications on their plan's approved list usually will be less expensive.
PHI (Protected Health Information) The HIPAA Privacy Rule that provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information.
Place of Service Myndview allows you to submit a location where care is being provided.
Plan May be used interchangeably with Payer, but Plan entails the type of program the Payer is providing to its members. Medicaid and Medicare are types of plans. Commercial plans are described as health insurance through employers. 
Portal A link provided in the Myndview Transaction Response after a provider runs a Prior Auth Requirements (PAR) transaction; shows where the information came from.  
Post Acute Post-acute care refers to a range of medical care services that support the individual's continued recovery from illness or management of a chronic illness or disability.
Primary Insurance Health insurance plan that covers a person as an employee, subscriber, or member. Primary insurance is billed first when a patient receives care.
Prior Authorization

A health plan cost-control process that requires health care providers to obtain approval for certain procedures, tests, and medications to assess the medical necessity and cost-of-care ramifications before they are authorized.
Procedure Code

This is a numeric or alphanumeric identifier for the classification of medical service; used for billing and tracking purposes. A single operation or treatment may include several procedure codes.
Provider A healthcare provider is a person or entity that provides medical care or treatment.
Secondary Insurance Coverage you can buy separately from a medical plan. It helps cover you for care and services that your primary medical plan may not. This secondary insurance could be a vision plan, dental plan, or an accidental injury plan. 
Service Provider Person who provides medical, technical, or other services designed to diagnose, treat, aid in the diagnosis and/or treatment of or otherwise impact the health status of an individual. 
Transaction Myndview has four transaction types: Benefits Eligibility and Verification, Patient Financial Responsibility, Prior Authorization Requirements, and Prior Authorization Submission.
Value Based Care A system of setting the cost for a healthcare service in which healthcare providers are paid based on the quality of care they provide rather than the number of healthcare services they give or the number of patients they treat.
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