Insurance Terms

Below you will find a glossary of commonly used insurance terms to assist you in better understand the impact on you as the patient.

Co-payment: This is the portion of the payment that the patient has to pay for his/her procedure. Co-Payment could be in addition to Co-Insurance, it will depend on the benefit package that your employer has chosen.
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Co-Insurance: Is a portion of the cost of the procedure that you are having done and is a pre-set amount given by your insurance company, via your employer benefit package. This will generally come in the form of a specific percentage, (e.g. 10%, 20%, etc.)
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Deductible: Is a pre-determined amount, by your employer chosen benefit package, you will have to pay before you may use your insurance benefits.
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Authorization: Is a request that has to be completed by the medical office to the insurance company in order to keep the claim being denied initially when the medical office submits the claim(s) to your insurance company.
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Pre-Certification: This is another name for “authorization”. See authorization definition.
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Notification: This is an acknowledgement that has to be submitted by the medical office to your insurance company. This may be done in place of getting an authorization.
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E.O.B: Acronym for Explanation of Benefits. This is a sheet of paper sent by your insurance company to you in order to keep you informed of claims that have been submitted with your Insurance Identification Number. These are not bills, but if there are any questions you should contact the medical office that submitted the claim(s) and/or your insurance company.
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TPA: Acronym for Third Party Administrator. This is when your insurance company has outsourced specific actions to another company.
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NIA: Acronym for National Imaging Association. This is a TPA (see TPA definition above) that is utilized by some insurance companies to complete the authorization process of your appointment. Used for authorizations and pre-certification of Radiology and Diagnostic Radiology exams and procedures. Claims may have to go to NIA before they go to your insurance company to be paid.
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MedSolutions: This is a TPA (see TPA definition above) that is utilized by some insurance companies to complete the authorization process of your appointment. Used for authorizations and pre-certification of Radiology and Diagnostic Radiology exams and procedures. Claims may have to go to MedSolutions before they go to your insurance company to be paid.
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One Call Medical: This is a TPA (see TPA definition above) that is utilized by some insurance companies to complete the authorization process of your appointment. Used for authorizations and pre-certification of Radiology and Diagnostic Radiology exams and procedures. Claims may have to go to One Call Medical before they go to your insurance company to be paid.
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Payor: Is the company or division of a company that is contracted with the medical office to pay the claims on your behalf, also known as your insurance company.
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Office Notes: When you see this on your E.O.B. (see E.O.B. definition), this is a request from your insurance company to the referring doctor not the medical office where the procedure was completed.
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Referral: A script from the referring doctor to the facility where your procedure needs to be completed. This will need to be done in addition to getting an authorization, pre-certification or notification.
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