Account Number
This is a number assigned to identify each episode of care. This number is used to track services and payments. This term is sometimes referred to as visit number.
Advance Beneficiary Notice (ABN)
This is a written notice given to you by a doctor, provider or supplier in advance of any service that Medicare may not consider covered. Also known as a waiver of liability, the ABN is given when providers offer a service or item they believe Medicare will not cover. ABNs only apply if you have Original Medicare, not if you are enrolled in a Medicare Advantage private health plan.
Allowable (Allowed Amount)
This refers to the maximum amount that an insurance company is willing to pay for covered medical services or procedures. Please note that Mayo Clinic doesn't accept predetermined usual, customary and reasonable (UCR) health insurance payment amounts for health plans with which Mayo Clinic doesn't participate. "Allowable" charges are sometimes known as reasonable and customary (R&C) charges.
Ambulatory care
Ambulatory care is care provided in the doctor's office or surgical center on an outpatient basis, without an overnight stay.
Appeal
An appeal is a request for your health insurer or plan to review a decision or a grievance.
Authorization
Authorization is the approval of care, such as hospitalization, by an insurer or health plan. Your insurer or health plan may require pre-authorization before you're treated.
Balance
Balance is the amount owed to Mayo Clinic indicated on the billing statement.
Balance billing
Balance billing is the practice of a provider billing you for all charges not paid by your insurance plan, even if those charges are above the plan's usual, customary and reasonable (UCR) charges or are considered medically unnecessary. Managed care plans and service plans generally prohibit providers from balance billing except for allowed copayments, coinsurance and deductibles.
Billing addressee (guarantor)
A billing addressee (guarantor) is the person designated to receive the monthly billing statements. This person can coordinate the billing, payment and insurance coverage for the account.
Certification
Certification is the official authorization for use of services.
Claims review
Claims review is the review your insurer or health plan performs before paying your provider or reimbursing you. This review allows the insurer to validate the medical appropriateness of the services given and review the charges related to your care.
Coinsurance
Coinsurance is a cost-sharing arrangement in insurance, where the policyholder is required to pay a percentage of covered expenses for a particular healthcare service, while the insurance company covers the remaining percentage. After a policyholder meets their deductible, they may be responsible for paying a certain percentage (coinsurance) of the covered medical costs, while the insurance company covers the rest. Commonly expressed as a percentage (for example, 20% coinsurance), this arrangement helps share the financial responsibility between the insured and the insurer, promoting cost sharing and potentially reducing the overall insurance premium.
Commercial health insurance
Commercial health insurance, also known as private insurance, is nongovernment insurance that pays all or some portion of medical bills. It may be purchased by individuals or by employers and is most often obtained as an employment benefit.
Coordination of benefits (COB)
Coordination of benefits is an agreement between your insurers to prevent double payment for your care when more than one plan provides coverage. The agreement determines which insurer has primary responsibility for payment and which has secondary responsibility.
Copay Accumulator
Copay accumulator is a feature or program within an insurance plan whereby a manufacturer's payments do not count toward the patient's deductible and out-of-pocket maximum. The manufacturer copay card or coupon funds prescriptions until the maximum value on the copay card or coupon is reached. After that, the patient's out-of-pocket costs begin counting toward their annual deductible and out-of-pocket maximum.
Copay Assistance
Copay assistance is a program offered by drug manufacturing companies as a direct way to lower out-of-pocket costs for drug costs for eligible patients. Copay assistance is financial assistance that helps all commercial insured patients pay for medical out-of-pocket expenses (that is, copay, coinsurance and deductible). Generally, these programs do not have income limitations.
Copay Maximizer
Copay maximizer is a feature or program within an insurance plan whereby a manufacturer's payments do not count toward the patient's deductible and out-of-pocket maximum. The maximum value of the manufacturer's copay card or coupon is applied evenly throughout the benefit year.
Copayment
Copayment is the portion of a claim or medical expense that you must pay out-of-pocket. Copayment usually is a fixed amount.
Cost share
Cost Share refers to the division of healthcare expenses between the insurance provider and the policyholder. Cost share generally includes deductibles, coinsurance, copayments or similar charges. It does not include premiums, balance billing amounts for non-network providers or the cost of noncovered services.
Covered charges
Covered charges are services that are typically covered under the terms of your contract with your insurance company. It is important to note that even though services may be covered charges, they are often subject to your deductible and coinsurance.
Credit balance
Mayo Clinic may owe a refund to the patient or insurance plan, dependent upon review of the account.
Current Procedural Terminology (CPT) codes
Current procedural terminology (CPT) codes are a set of five-digit codes used by medical professionals for billing and authorization of services.
Deductible
A deductible is the portion of your healthcare expenses that you must pay out-of-pocket before your insurance applies and begins to contribute toward covered expenses.
Denial or denied
A service for which your healthcare plan has determined the provisions of your benefit plan do not have benefits available or there are certain limitations as to when the benefits are available. If your insurance denies benefits for a service, you are liable for the entire amount.
Diagnosis-Related groups (DRGs)
DRGs are a system of classifying inpatient stays for payment. The Centers for Medicare & Medicaid Services uses DRGs to derive standard reimbursement rates for medical procedures and to pay hospitals for Medicare recipients. Some states use DRGs for all payers, and some private health plans use DRGs for contracting.
DOS
DOS is an abbreviation for "date of service."
Elective services
Medical procedures, treatments or interventions that are planned in advance and are considered nonemergent or nonurgent care. With few exceptions, cosmetic procedures are elective services and must be prepaid by the patient.
Explanation of benefits (EOB)
An explanation of benefits is a statement provided to an insured person noting how a claim was paid or why it wasn't covered. Medicare recipients receive a Medicare Summary Notice (MSN).
Fee schedule
A fee schedule is a predetermined list of charges or fees established by a healthcare provider, facility or insurance company for specific medical services, procedures or treatments. Some plans refer to it as fee maximums or as a fee allowance schedule.
Grant Assistance
Grant assistance refers to programs that offer financial assistance to help patients pay for out-of-pocket expenses toward their specific disease. Grants help pay for various medical expenses including out-of-pocket liability (that is, copay, coinsurance and deductible), insurance premiums, and some even cover lodging and travel. These are independent programs that help people with life-threatening, chronic and rare disease get the medication and treatments they need by assisting with their out-of-pocket costs and advocating for improved access and affordability.
Guarantor ID
The guarantor ID on the statement is the billing account number. Refer to this number when contacting Mayo Clinic with questions.
HCFA 1500 form
The HCFA 1500 form is the officially recognized standard document utilized by physicians and other healthcare professionals for submitting invoices and claims to request reimbursement for outpatient services from Medicare, Medicaid and private insurance companies.
Health maintenance organization (HMO)
An HMO can be defined in several ways: 1. An organization that provides healthcare to members in return for a preset amount of money. 2. A type of health insurance plan that limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may also use referrals from primary care providers to determine whether members receive care from specialists.
Hospice
A hospice is a facility or program that provides care for people who are terminally ill. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional and spiritual needs of the patient. Hospice care is covered under Medicare Part A (hospital insurance).
In-network provider
A provider who has a contract with your health insurer or plan to provide services to you. An in-network provider is also known as a preferred provider.
International Classification of Disease (ICD) codes
ICD codes are an international disease classification system used in diagnosis and treatment.
Itemized statement
An itemized statement is an itemized list of services provided. The itemized statement of charges includes the CPT and diagnosis codes used when submitting a claim to an insurance plan. An itemized statement is not a bill.
Managed healthcare
Managed healthcare refers to a system of healthcare delivery that tries to manage the costs and quality of healthcare and access to care. It often involves use of contracted provider networks, limitations on benefits for care given by noncontracted providers (unless authorized to do so) and use of care authorization systems. Managed care includes managed indemnity plans, preferred provider organizations, point-of-service plans and health maintenance organizations (HMOs).
Mayo Clinic contracted services
Mayo Clinic contracted services are patient services for which Mayo Clinic has a contract with a specific insurance company to accept a contractually set amount for these medical services.
Mayo Clinic number
This is your personal identification number at Mayo Clinic. It's unique, and it will be your Mayo Clinic number for life.
Medicaid (Title XIX)
Medicaid is a program financed jointly by the federal government and the states that provides healthcare coverage and nursing home care for low-income individuals and families. Benefits vary widely from state to state. Title XIX refers to the specific title of the Social Security Act that authorizes and outlines the Medicaid program.
Medicare (Title XVIII)
This is a federally funded program that provides coverage for eligible individuals, primarily those age 65 and older, as well as certain younger individuals with qualifying disabilities, regardless of financial status. It consists of two separate but coordinated programs: hospital insurance (Part A) and supplementary medical insurance (Part B), and also a separate drug coverage program administered by the private sector (Part D).
Medicare Advantage Plan (Medicare Part C)
Medicare Advantage Plans are offered by private companies that contract with Medicare to provide both Medicare Part A and Part B benefits. Medicare Advantage Plans may be HMOs, preferred provider organizations (PPOs) or private fee-for-service plans. When a person is enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan. Services aren't paid for under Original Medicare.
Medicare assignment
Medicare assignment means that your doctor, provider or supplier agrees to accept the Medicare-approved amount as full payment for covered services. Most doctors and providers accept assignment, but you should always check to make sure. Mayo Clinic's Arizona, Florida and Minnesota campuses accept Medicare assignment.
Medicare nonassignment
Providers that do not accept assignment are called nonparticipating providers and have not signed an agreement form to accept assignment for all Medicare-covered services. Most doctors and providers accept assignment, but you should always check to make sure.
Mayo Clinic will submit a claim to Medicare charging up to 15 percent over the Medicare approved amount. If you have a Medicare supplement policy, it may or may not cover the 15 percent “Medicare excess” charge.
To pay your bill or ask questions about your statement, please contact us by phone.
Call Patient Account Services at 844-217-9591 (toll-free), Monday through Friday.
All Mayo locations
Monday through Thursday
7:00 a.m. to 7:00 p.m. Central time (during daylight saving time)
7:00 a.m. to 6:00 p.m. Central time (during standard time)
Friday
7:00 a.m. to 4:00 p.m. (year round)
Medicare sequestration
Effective April 1, 2013, Medicare claims with dates of service or dates of discharge on or after April 1, 2013, will incur a 2% reduction in Medicare payment. The claims payment adjustment shall be applied to all claims after determining coinsurance, any applicable deductible and any applicable Medicare secondary payment adjustments. Though beneficiary payments for deductible and coinsurance are not subject to the 2% payment reduction, Medicare's payment to beneficiaries for nonassigned claims is subject to the 2% reduction. Questions about reimbursement should be directed to your Medicare claims administration contractor.
Medicare Summary Notice
This is a statement Medicare provides to Medicare enrollees explaining how it processed and paid a claim.
Medigap
Medigap, also known as Medicare Supplement Insurance, is private insurance that supplements Medicare reimbursement for medical services. Medicare often reimburses care at lower rates than those charged by doctors. Medigap is meant to cover the gap between Medicare reimbursement and provider charges so that the Medicare recipient doesn't have to pay the difference.
Monthly statement of account
A monthly statement of account is your Mayo Clinic bill.
Noncovered charges
Noncovered charges are services that are not a covered benefit under the provisions of your insurance plan. If your insurance does not cover a service, you are liable for the entire amount. This is specific to your insurance policy.
Noncovered services
Noncovered services are services not covered under the limits of the patient's health insurance contract. These amounts are the patient's responsibility to pay. Patients should direct questions about coverage to their health plans.
Nonparticipation
Nonparticipation refers to the choice by a healthcare provider not to participate in a particular health insurance plan or network. When providers do not participate, they have not entered into an agreement with the insurance company to accept their payment terms, including reimbursement rates and other conditions.
Out-of-network
An out-of-network healthcare professional does not have a contract with your health insurer or plan to provide services to you. You'll pay more to see an out-of-network or nonpreferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a "tiered" network and you must pay extra to see some providers.
Per diem reimbursement
In per diem reimbursement, an institution such as a hospital receives a set rate of compensation per day, rather than reimbursement for charges for each service provided. Per diem reimbursement can vary by service (for example, medical or surgical, obstetrics, mental health, and intensive care) or can be a set rate.
Pharmacy benefit managers
Pharmacy benefit managers are third-party administrators of prescription drug programs used by a variety of sponsors, including commercial health plans, self-insured employer plans, Medicare Part D plans, the Federal Employees Health Benefits Program and others.
Point-of-service (POS) plan
A point-of-service plan is one in which members don't have to choose the coverage for services until they need them. Most often, the plan enrolls each member in both an HMO (or HMO-like) system and an indemnity plan. These plans provide different benefits depending on whether the member stays within the plan. Dual choice refers to an HMO-like plan with an indemnity plan, and triple choice refers to the addition of a PPO to the dual choice.
Pre-Service Payment
A pre-service payment is, when applicable, a dollar amount predetermined by Mayo Clinic to be paid before your visit.
Pre-certification
Pre-certification also is known as pre-admission certification, pre-admission review and pre-cert. It refers to the process of obtaining authorization from the health plan for routine hospital admissions and surgical encounters (inpatient or outpatient). Failure to obtain pre-certification often results in reduced reimbursement or denial of claims.
Preferred provider organization (PPO)
A preferred provider organization (PPO) offers members greater flexibility in choosing healthcare professionals while offering financial incentives for using providers within the plan's preferred network. The doctors in a PPO are paid on a fee-for-service schedule that is discounted below standard fees. The panel of providers is limited, and the PPO usually reviews healthcare utilization. PPO members sometimes can use a doctor outside the PPO network, but usually must pay a bigger portion of the fee.
Primary care physician (PCP)
A primary care physician, also called a PCP or "gatekeeper," usually is the first doctor you see for an illness. Your doctor treats you directly, refers you to a specialist (secondary care) or admits you to a hospital. Your primary care physician may be a family doctor, internist, pediatrician or, occasionally, an obstetrician or gynecologist.
Primary insurance company
The primary insurance company is the insurance company with first responsibility for the payment of the claim.
Prior authorization, also called prior written approval
Prior authorization is a process used by health insurance plans to determine in advance whether a specific medical treatment, procedure, prescription medication or healthcare service is medically necessary and meets the criteria for coverage. This process involves obtaining approval from the insurance company or plan before the service is rendered or the treatment is initiated.
Provider
A provider is any supplier of healthcare services, such as doctors, pharmacists, physical therapists and others.
Proof of health insurance
Proof of health insurance refers to documentation or evidence that an individual has an active health insurance policy in place. This documentation serves to confirm that the person is covered by a health insurance plan, and it typically includes key information such as the policyholder's name, the insurance company details, policy number and information about the coverage provided.
Reasonable and customary (R&C)
Reasonable and customary (R&C), also called allowable or allowed amount, refers to the maximum amount that an insurance company is willing to pay for covered medical services or procedures. Please note that Mayo Clinic doesn't accept predetermined health insurance payment amounts for health plans with which it doesn't participate. R&C also may be known as UCR.
Referral
A referral is a written order from your primary care provider for you to see a specialist or get certain medical services. In many health maintenance organizations (HMOs), you must obtain a referral before receiving medical care from anyone except your primary care provider. If you don't get a referral approved by your insurance first, the plan may not pay for the services.
Registration
Registration refers to the process by which individuals officially enroll or register with a healthcare professional or system to receive medical services. The process involves gathering necessary information about the patient, creating a record in the healthcare system, and establishing a relationship between the patient and the healthcare professional or institution. Registration also refers to areas in the lobbies of Mayo Clinic facilities where all patients report to be assigned a Mayo Clinic medical record and billing account number. Here, they also can receive information about payment, billing and filing insurance. All address, phone and insurance changes should be updated whenever changes to them occur.
Secondary insurance company
A Secondary insurance company is the insurance company responsible for processing the claim after the primary insurance determines what it will pay.
Self-insured plan
In a self-insured (self-funded) plan, the employer (rather than an insurance company or managed care plan) assumes the risk of medical costs. Self-funded plans are exempt from state laws and regulations such as insurance premium taxes and mandatory benefits. Self-funded plans often contract with insurance companies or third-party administrators to administer the benefits.
Self-pay patient
A self-pay patient is a patient who has no insurance or does not want the services rendered to be filed with his or her insurance company. This patient must make a pre-service payment.
Skilled nursing facility (SNF)
A skilled nursing facility generally is an institution for convalescence or a nursing home. Skilled nursing facilities provide a high level of specialized care for long-term or acute illness.
Statements
You will receive a monthly statement of account that shows charges, adjustments and payments.
You may access your statements online by using Mayo Clinic Patient Online Services.
- In compliance with Florida price transparency requirements, itemization includes descriptions of each service provided. Itemized statements also include the brand name or generic drug names when provided. In addition physical, occupational, and speech therapy services are identified by date, type, and length of treatment in 15 minute increments.
Upon request, if additional detail is available Mayo Clinic will provide a more detailed statement to you within 7 business days after the request, or 7 business days after discharge or release, whichever is later. You may request this more detailed statement by phone.
Call Patient Account Services at 844-217-9591 (toll-free), Monday through Friday.
All Mayo locations
Monday through Thursday
7:00 a.m. to 7:00 p.m. Central time (during daylight saving time)
7:00 a.m. to 6:00 p.m. Central time (during standard time)
Friday
7:00 a.m. to 4:00 p.m. (year round)
Supplemental insurance
Supplemental insurance is any private health insurance plan held by a Medicare or commercial beneficiary, including Medigap policies or post-retirement benefits. Supplemental insurance helps to cover out-of-pocket expenses, copayments, deductibles and other costs not fully covered by the primary plan, and sometimes will pay the entire bill when primary insurance benefits have reached their limits.
Supplemental or secondary claim form
If you have supplemental or secondary insurance, Mayo Clinic will submit claims to those carriers on your behalf.
Third-party administrator (TPA)
Third-party administrators handle the administrative duties and sometimes utilization review for self-funded plans.
Tier network
With a tiered network product, the member's benefit level of cost sharing is determined by the network of the independently contracted provider that renders the service. Keep in mind that an employer can customize the benefit levels for each tier. Here is an example of a basic benefit structure of a tiered product: Tier 1 is the highest benefit level and most cost-effective level for the member, as it is tied to a narrow network of designated providers. Tier 2 benefits offer members the option to select a provider from the broader network of contracted providers, but at a higher out-of-pocket expense. Tier 3 benefits, if offered, typically address the use of out-of-network providers as the highest cost option for covered services, which are subject to usual, customary and reasonable charges.
UB04 form
The UB04 form is the officially recognized standard document utilized by physicians and other healthcare professionals for submitting invoices and claims to request reimbursement for inpatient services, nursing homes and rehabilitation centers from Medicare, Medicaid and private insurance companies.
Uninsured patient
An uninsured patient is a patient without public or private health insurance. Mayo Clinic requires uninsured patients to make a deposit before receiving care.
Usual, customary and reasonable (UCR) charge
The usual, customary and reasonable charge (UCR), also known as allowable or allowed amount, refers to the maximum amount that an insurance company is willing to pay for covered medical services or procedures. This term may be synonymous with allowable, fee allowance schedule, and reasonable and customary (R&C).
Utilization limits
Medicare sets limits on how many times some services can be provided in a year. If services exceed this utilization limit, your claim could be denied. These limits are not disclosed to Mayo Clinic.
Utilization review
Utilization review is a process of tracking, reviewing and rendering opinions about care. The practices of pre-certification, recertification, retrospective review and concurrent review all describe utilization review methods.
Visit number
The visit number is a number assigned to identify each episode of care. This number is used to track services and payments. Visit number is also referred to as account number.
Workers' compensation coverage
Workers' compensation coverage is insurance that employers are required to have to cover medical care of employees who incur an injury or illness on the job.
