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GLOSSARY OF TERMS
Allowable
The amount of money for which your insurance company will allow a claim to be processed. The client's co-insurance is usually based on their allowable amount. For example, if the allowable amount is $5,000.00, and the client's co-pay is 10%, the amount the client will owe is $500.00.
Assignment of Benefits (AOB)
Form signed by the policy holder that allows the insurance company to pay ZYGO Industries, Inc. or its dealers directly. Without an AOB, the policy holder may receive the insurance payment.
Certificate of Medical Necessity (CMN)
This is usually a state-specific form which is signed by the physician or speech therapist.
Claim
Billing submitted to the insurance company after the equipment has been delivered.
Client Advocate
Person who is representing the client during the funding process. This person is usually a speech therapist or case manager.
CPT Code
The Current Procedural Terminology code describes the type of services that are being supplied. This is generally the same as a HCPC Code.
Custodial Care Facility
Facility that provides room, board, and assistance with daily living activities, such as feeding and dressing. This care is generally on a long term basis and does not entail the continuing attention of trained medical personnel.
Deductible
That amount that the client must pay annually before benefits will be paid by the insurance company.
Durable Medical Equipment (DME)
Systems made to withstand repeated use that are used for the treatment of an injury or disease. Speech Generating Devices have been classified as Durable Medical Equipment.
Explanation of Benefits (EOB)
The statement from the insurance company showing the services and amounts that were paid by the policy. This is also known as a remittance.
Exclusions
Services for which the insurance company will not pay.
Funding Questionnaire (FQ)
A questionnaire that is usually completed by a family member or other contact person which includes important information such as the client's address, physician, insurance information, and a list of the equipment that they wish to order.
HCPC
Code that is used to describe the services rendered. For example, the Polyana with Persona has a Medicare HCPC code of E2510.
Hospice
Supportive care given to a terminally ill client and their family. The focus of this care is to enable the client to remain in the familiar surrounding of their home for as long as they can. Hospice care may be either inpatient or outpatient.
ICD-9 Code
International Classification of Diseases. Insurance code that describes a client's medical condition or diagnosis.
Insurance Letter of Requirement (ILR)
This letter is sent to your insurance company by your funding coordinator and explains the details that should be included in a private insurance authorization. An approval form is also included with this letter. Insurance companies may complete the approval form instead of creating a letter.
Invoice
Itemized statement explaining what items or services have been delivered.
Letter of Medical Necessity (LMN)
A letter explaining the medical need for AAC services. This letter can be written by a physician, speech therapist, or occupational therapist. These letters usually give the client's diagnosis and a brief explanation of why services are necessary.
Maximum Out of Pocket
The maximum amount a client will pay towards their deductible and 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
State-sponsored medical plan. Eligibility for these plans is traditionally based on a family's income. May also be called Title 19.
Medicare
Federally-sponsored medical plan. Clients become eligible for this program when they turn age 65 or have a qualifying disability. There are two separate programs under Medicare
Part A (hospitalization) and Part B (medical). Clients must pay a monthly fee for Part B coverage. speech generating devices are covered under Medicare Part B.
Medicare Supplement
An insurance policy that covers Medicare co-payments and other services. This policy must be purchased by the Medicare beneficiary.
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.
Original Documentation
Prescription and speech evaluation that has an original signature. The signature page on the evaluation and the doctor's prescription cannot be stamped, copied, or faxed. Medicare requires that original documentation be on file with the vendor for any product.
Payment Agreement (PA)
Form signed by a policy holder stating that they agree to cover any amounts not paid by the insurance company.
Place of Service (POS)
The location where the medical services will be provided or used. It is important that we know whether a client lives at home, in a group home, or in a nursing facility. Some funding sources will not cover clients that live in a nursing facility.
Pre-certification
See Prior Authorization.
Pre-determination
A review done by an insurance company to determine whether a service will be considered a covered benefit.
Prior Authorization
Approval issued by the insurance company before equipment is delivered. Authorizations are normally issued by nurse reviewers at the insurance company who review the doctor's orders and other documentation to ensure that a service is medically necessary.
Referral
Specific directions or instructions from a client's primary care physician. Referrals may be on paper or electronic and are usually required by HMO policies.
Release of Information (ROI)
A form that is signed by a client or their guardian and gives permission for the vendor to release medical documentation to insurance companies and other funding sources.
Remittance
A statement sent to medical providers from the insurance company to show the payment that was issued. Also called Explanation of Benefits (EOB).
Rx
Prescription. This must be signed by a medical doctor or dentist.
Sole Source Supplier
A provider who is the only source for a particular service or type of equipment.
Subscriber
The employee covered under an employer's group insurance policy. Also referred to as the policy holder.
Skilled Nursing Facility (SNF)
A facility which provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but do not require the level of care provided in a hospital. If a person is in this type of facility, they are not able to use Medicare as a funding source.
Stop Loss
See Maximum Out of Pocket.
UPIN
Unique Physician Identification Number. Identification number that is used to identify the physician who signed the prescription. This number is used when filing claims to insurance companies.
Usual and Customary Charges
Also referred to as Reasonable and Customary Charges. An amount determined by an insurance company that represents a routine charge for a medical service by similar medical and professional providers in the same geographical area. Allowable amounts are normally based on the Usual and Customary Charges.
Documentation Requirements
& Forms