Glossary - Basic

The Glossary of Insurance and Medical Billing Terms

ICD-9

A 3 to 5-digit number code describing a diagnosis or medical procedure.
Inpatient A patient who is admitted to a hospital and receives medical services from a physician during at least a 24-hour period.

In-Network Provider

Physicians and other service providers who are contracted with a managed care plan.

Out-of-Network Provider

Physicians who are not contracted with a managed care plan.

Outpatient

A patient who receives health care services, but is not admitted to a hospital during a 24-hour period.

Primary Care Physician

A physician, usually a general, family practitioner or internist, who delivers general health care, and is most often the first doctor a patient sees. This physician treats the patient directly, refers them to a specialist (or secondary care physician) or admits them to the hospital.

Provider

A physician, hospital, laboratory, pharmacy or other organization that provides health care, goods or services.

Pre-Certification

Also known as pre-admission certification, is the process of obtaining authorization from the health care plan for routine inpatient and outpatient admissions. Failure to obtain pre-certification may result in penalty to the provider or the subscriber.

Referral Authorization

Approval for a member to see a physician or access services outside of the participating medical group.

Referral Physician

A physician who sees a patient after another doctor has sent them for specialty care or services.

Referring Physician

A physician who sends a patient to another doctor for specialty care or services.

Subscriber

A person who enrolls in a health care plan and agrees to pay for premiums, co-payments and deductibles that are part of the plan.

Treating Physician

A physician who provides care to the patient while in the hospital, and usually works at the hospital or comes in as a specialist.

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