Billing Glossary
The portion of your bill that is adjusted in accordance to the contract between Wake Forest Baptist and your insurance company.
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 your benefit package.
The portion of your bill, as agreed with your insurance company, that you owe your medical provider.
The transfer of the right for reimbursement directly to the provider of plan benefits from the insured person to a health care provider.
The services that are covered under your insurance plan.
An amount set for services before any discounts. The charge amount is then adjusted based on our contracts with payers, financial assistance policy, and uninsured patient discount. Patient pay charge best represents costs a patient without insurance could incur for services.
The bill for your services that the hospital and/or physician sends to your insurance company for payment.
The portion of your covered services that your insurance company requires you to pay after meeting your deductible.
A set fee established by your insurance company for a specific type of visit.
A group policy provision which helps determine the primary carrier in situations where an insured is covered by more than one policy.
Costs to a hospital would mean total expenses incurred to provide the health care. Cost to a patient would mean their total expenses incurred to satisfy their financial obligation (see deductible, co-insurance, co-payment, out-of-pocket costs).
A health care service, your insurance company agrees to pay a pre-established rate and/or percentage for.
The date you were provided healthcare services.
The amount of money, as determined by the benefit plan that a person must pay for authorized health care services before insurance payment commences. Deductibles are usually calculated on a calendar year basis, but can also be based on the anniversary date of a patient's effective date with that plan or plan year of the named insured or subscriber.
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.
The person or entity who is financially responsible for payment on a patient's account. Usually the patient is financially responsible for medical charges. A parent or legal guardian/trustee is the guarantor for patient's 18 years of age and younger. This is also the case for patients with a decreased mental capacity.
A patient is an inpatient when the physician orders an "inpatient admission."
Medicare is a federal insurance program which primarily serves those over 65 years old and younger, disabled people and dialysis patients. Medicare is divided into two parts:
- Medicare Part A covers inpatient hospital services, nursing home care, home health care and hospice care.
- Medicare Part B helps pay the cost of doctors' services, outpatient hospital services, medical equipment and supplies and other health services and supplies.
A supplemental private insurance policy to help cover the difference between approved medical charges and benefits paid by Medicare.
A cost incurred by the patient when his/her insurance policy does not cover.
Services rendered by a provider which does not have a contract to offer you care. Typically, managed care plans are contracted with a panel of providers. If a patient seeks 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.
The amount that is paid by the patient or guarantor.
The maximum yearly amount that is paid by the patient or guarantor.
A treatment or service you receive that does not require hospitalization.
Outpatient hospital departments are those that meet the same higher standards for physical setting and patient care as required for a hospital. A large number of Wake Forest Baptist clinics are outpatient hospital departments.
A number your insurance company gives you to identify you and/or your coverage.
This number represents the agreement by the insurance company that the services has been approved. This is not a guarantee of payment.
A health condition or a medical problem acknowledged by your insurance company as not covered as a benefit.
The amount actually paid to a hospital. Price is less than charge. A portion could be paid by the insurance provider and a portion paid from the patient.
- The primary care physician (can be an internist, pediatrician, family physician, or OB/Gyn) is responsible for all general medical care of the patients and referrals to specialists for tertiary care when medically appropriate.
- The PCP is responsible for providing or authorizing all care (hospitalization, diagnostic, workups and specialty referrals) for that patient.
- Depending on the type of insurance plan, a patient may not be covered for a visit to a specialist without prior approval of the primary care provider.
The insurance company responsible for paying your claim first.
A hospital or physician who provides medical care to the patient.
Provider-based billing is another name for how Wake Forest Baptist bills for our hospital-designated clinics. In brief, it's a way that federal payers like Medicare use to recognize the higher standard of care provided in clinics like those at Wake Forest Baptist.
The cost for medical services that insurance companies believe are appropriate throughout the geographic area or community.
A physician's medical order for services or consultations to be provided by a specialist.
The person responsible to pay the bill.
The insurance company responsible for paying the balance of your claim after the primary insurance company has determined benefits.
If you do not have insurance, or if you are seeking care at Wake Forest Baptist outside of your insurance plan benefits, you are considered a self-pay patient. See Financial Assistance policy.