Referral - approval needed for care beyond that provided by a primary care physician or hospital.  For example, HMOs usually require referrals from a primary care physician to see specialists.

Release of information - A signed statement from patients or guarantors that allows doctors and hospitals to release medical information so that insurance companies can pay claims.  See also coding of claims.

Revenue code - a billing code used to classify charges based on the type of service, supply, or procedure provided.

Same-day surgery - outpatient surgery.

Secondary insurance - extra insurance that may pay some charges not paid by primary insurance.  Whether payment is made depends on the beneficiary's insurance benefits, coverage, and coordination of benefits.

Self-administered drug - For patients that are not admitted as an inpatient, these are drugs that do not require doctors or nurses to help the patient take them.  Since Medicare will not pay for these drugs when they are taken in the hospital on an outpatient basis—even if a doctor or nurse helps them take the drugs—patients are charged for them.  Self-administered drugs may include ointments, inhalers, insulin, or any other medicine the patient may normally take at home.

Self-insured plan – an insurance plan where financial risk for medical expenses is assumed by the group (usually an employer) rather than an insurance company.  Self-insured plans are often administered by TPAs.  Also known as self-funded plan.

Skilled Nursing Facility (SNF) – a facility, either free-standing or part of a hospital, that accepts patients seeking rehabilitation and medical care that is less intense than that received in a hospital.

Source of admission - the way a patient was admitted to the hospital, such as from a physician referral, a transfer from another hospital, an emergency room visit, etc.

Specialist - a doctor who specializes in treating certain body parts, specific medical conditions, or certain age groups.  For example, cardiologists only treat patients with heart problems.

Sub-acute care – a comprehensive inpatient program for patients with a serious illness, injury, or disease who do not require intensive (acute care) hospital services.  A range of services may be considered sub-acute, including infusion therapy, respiratory care, cardiac services, wound care, and rehabilitation services.

Swing bed - bed for a patient who receives skilled nursing care in a non-skilled nursing facility.

Third Party Administrator (TPA) – an independent company (third party) that administers group benefits, processes claims, and performs other administrative tasks for a self-insured company or group but does not assume any financial risk for the insurance plan’s performance.

TRICARE – Insurance for active and retired military personnel, their families, and other dependents.  Formerly known as CHAMPUS.

UB-92 - a billing form used by hospitals to file insurance claims for medical services.

Units of service - measure of quantity for medical services, such as the number of hospital days, pints of blood, etc.

Usual, Customary, or Reasonable  (UCR) – the amount insurers believe to be the common or prevailing charges for services provided in a region or community.

Utilization Review (UR) – a formal assessment (or the hospital staff who conduct the assessment) of the medical necessity, efficiency and/or appropriateness of services and treatment plans for a patient on a prospective, concurrent, or retrospective basis.

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