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.
