Current Procedural Terminology (CPT) is the code set used to bill outpatient and office procedures.
The International Statistical Classification of Diseases and Related Health Problems (ICD) is a medical classification list by the World Health Organization (WHO) that contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injuries or diseases.
Network refers to the health care providers and facilities that are contracted with a specific health insurer/plan. A preferred provider or in-network provider is one who has a contract with the insurer/plan to provide services to individuals with that plan. A non-preferred provider, also known as an out-of-network provider, is one who does not have a contract with the insurer/plan to provide services to individuals with that plan.
A copay, or copayment, is a fixed dollar amount an individual pays for health care services. Copays vary for different services such as specialist visits, prescription drugs, and emergency department visits.
A deductible is the amount an individual owes, for health care services covered by a health insurance plan, before the insurance/plan begins to pay. For example, if one's deductible is $500, the plan will not pay anything until the individual has paid the $500 deductible.
Global payments, or payment bundles, are fixed-dollar payments for the care a patient may receive in a given time period, such as 1 month or 1 year. This payment model places providers at financial risk for both the occurrence of medical conditions as well as the management of those conditions. This payment model is intended to contain costs and reduce the use of unnecessary services and encourage integration and coordination of services. It may also include added incentives to improve the quality of care.
The Medicare Access and Chip Reauthorization Act (MACRA) of 2015 does the following:
A Preferred Provider Organization (PPO) is a type of health plan that has a network of participating health care providers. Individuals with a PPO plan pay less when using providers in the network. There is an additional cost for using providers outside of one's PPO network.
A formulary is a list of prescription drugs approved by a health plan.
An indemnity plan is a type of health plan in which an individual pays 100% of all covered charges up to an annual deductible. Once the deductible is met, the health plan then pays a percentage of covered charges.