The Technical Terms Used in Claim-processing
Part 1: The Basic Tools, Chapter 2: Understanding the Language of Health Insurance Page 10
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Table 5 - Technical Terms Used in Claim-processing
| Technical Term | Meaning |
| EOBS (Explanation of Benefits Statement) | A statement sent from the insurance company to the patient; lists charges, dates of service, and reimbursement |
| Medical Provider (Provider, Provider of Service) | A doctor, testing center, or hospital that provides treatment or medical services |
| Network or Plan Provider | A doctor, testing center, or hospital that is part of the insurance company's network and that has agreed to follow network rules |
| Therapy | A term that often refers to physical therapy, not to psychological or psychiatric treatment |
| Outpatient Treatment for Mental Illness | Therapy offered by a mental health provider such as a psychologist or psychiatrist on an outpatient basis |
| Documentation | The paperwork that insurers require before processing a claim; may include a letter of medical necessity, an operative report, or an itemized bill |
| Operative Report | A detailed report of the procedures performed during surgery |
| Letter of Medical Necessity | A letter from a doctor explaining why a specific medical test, treatment, or type of medical equipment is necessary |
| Not Medically Necessary | A phrase used to mean either that a claim cannot be processed until all of the required documentation has been provided, or that the insurer has determined that the claim does not meet the policy requirements, and is thus not considered a covered expense under the terms of the policy |
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