Glossary of Terms
Account Number: A unique number that is assigned in your medical record each time you visit the hospital.
Adjustment: A portion of your hospital bill that is adjusted in accordance to the contract between Queen of the Valley Medical Center (QVMC) and your insurance company.
Amount Not Covered: The billed amount that the insurance company will not pay. It may include deductibles, coinsurances, and charges for non-covered services. For example, a non-covered charge could be food trays for visitors, personal grooming supplies, take-home supplies, and private rooms.
Amount Payable by Plan: The amount your insurance plan pays for your treatment, less any deductibles, coinsurance, or charges for non-covered services.
Assignment of Benefits: The transfer of the right for reimbursement directly to the hospital or provider from the patient’s health care provider. Transferring rights allows the insurance company to mail any payment directly to the hospital or provider. This legal statement may be signed by the patient or his/her legal spouse or guardian.
Authorization: Permission for a patient service that is granted by the health insurance plan,
Medi-Cal group or the hospital.
Benefit: The services that are covered under your insurance plan.
Birthday Rule: Used to determine primary and secondary coverage for children when two parents have insurance coverage. The word "birthday" refers only to the month and day in a calendar year, not the year in which the person was born.
- If the parents are not separated or divorced, the insurance of the parent whose birthday occurs first in a calendar year is considered the primary insurance while the other parent's benefits are considered the secondary coverage.
- If the parents have the same birthday, the insurance plan that has covered the parent for the longest time is considered the primary insurance.
- In situations where the parents are separated or divorced and there is more than one insurance plan covering the child, the benefits are determined in the following order. **
- The insurance plan of the parent with legal custody of the child.
- The plan of the spouse of the parent with legal custody of the child.
- Last is the plan of the parent who does not have legal custody of the child.
** There can be some discrepancy, depending on a court decree, if there are no specific terms on a court decree (stating only that the parents share joint custody). The benefit determination is the same as if the parents are not separated or divorced.
California Children Services (CCS): The California Children Services (CCS) Program provides diagnostic and treatment services, Medi-Cal case management, physical and occupational therapy services to children under the age of 21 years with CCS-eligible conditions. An authorization from CCS is required for services.
COBRA Insurance: Health insurance coverage that you can purchase when you are no longer employed, or awaiting coverage from a new insurance plan to begin. Coverage may be purchased for up to 18 months from your date of separation. It is generally more expensive than insurance provided through the employer but less expensive than insurance purchased as an individual policy.
Coinsurance: The percentage of coverage not covered under your insurance benefits. For example, your policy may cover 80% of charges. Your coinsurance/patient portion is the remaining 20%.
Contracted Services: A contract between QVMC and a specific insurance company that specifies how much the insurance company will pay for certain medical services.
Coordination of Benefits (COB): A group policy provision which helps determine the primary carrier in situations where an insured is covered by more than one policy.
Co-payment/Co-pay: A set fee established by the insurance company for a specific type of visit. This amount is due from the guarantor. This information can routinely be located on the insurance card and will be different amounts according to the type of visit. For example, Emergency Room Visit - $50, Inpatient Stay - $100, Physician Office Visit - $20.
Date of Service (DOS): The date(s) when you were provided healthcare services. For an inpatient stay, the dates of service will be the date of your admission through your discharge date. For outpatient services, the date of service will be the date of your visit.
Deductible: An amount that must be paid on an annual basis. This amount is established by the insurance company and your benefit plan. Call your insurance company for the most up-to-date information regarding your deductible.
Explanation of Benefits (EOB): This is a notice you receive from your insurance company after your claim for healthcare services has been processed. It explains the amounts billed, paid, denied, discounted, uncovered, and the amount owed by the patient. The EOB may also communicate information needed by the insured in order to process the claim.
Financial Assistance Program (FAP): A St. Joseph Health (SJHS) program provided to uninsured or under insured QVMC patients who are unable to pay for hospital services. Individual QVMC patient eligibility determines if financial assistance will be granted on a full or partial basis.
Guarantor: The person responsible for payment of the bill. A parent or legal guardian/trustee is the guarantor for patient's 18 years of age and younger. This is also the case for patients with a decreased mental capacity.
Health Maintenance Organization (HMO): An insurance plan that has contracted with providers such as QVMC to provide healthcare services at a discounted rate. These services require prior pre-certification, authorization, and/or referrals.
Managed Care: An insurance plan that has a contract agreement with hospitals, physicians, and other healthcare providers.
Medicaid: A state administered, federal and state-funded insurance plan for low-income families who have limited or no insurance. MediCal is California’s Medicaid program.
Medi-Cal: Medi-Cal is California’s Medicaid program. Medi-Cal provides health services through a federal and state medical assistance program for categorically eligible and low-income persons. Eligibility determination is conducted through Local County Welfare Departments. If you are covered under the CA State Medi-Cal Program, you are required to provide eligibility card or proof of eligibility for each month of service. For questions concerning Medi-Cal call 1-800-541-5555 or visit them on the web at
Medi-Cal Managed Care: The conversion of fee-for-service Medi-Cal to PCP governed care whereby eligible recipients select a primary care physician who manages all care provided to the member.
Medicare: A health insurance program for people age 65 and older, some people with disabilities under age 65, and people with end-stage renal disease (ESRD). For questions concerning the Medicare program, call the Social Security Administration toll-free at 1-800-772-1213, visit them on the web at
http://www.medicare.gov/, or call your local Social Security office.
- If you are a Medicare patient, QVMC will prepare and submit your claims to Medicare on your behalf.
- QVMC accepts Medicare assignment of benefits; this means that QVMC will accept the amount that Medicare allows.
- After Medicare pays their portion of what they allow, QVMC Hospital will bill your supplemental insurance directly for the remaining balance, including Medicare deductibles and copayment amounts.
- Medicare patients may call the following phone numbers for assistance:
- Part A: (800) MEDICARE - Administered by Palmetto GBA
- Part B: (800) MEDICARE - Administered by Palmetto GBA
- HICAP: (800) 434-0222 - Health Insurance Counseling & Advocacy Program
Medicare Assignment: The Medicare-approved amount of payment to QVMC.
Medicare Part A (Hospital Insurance): Healthcare coverage for inpatient stays at participating hospitals.
Medicare Part B (Medical Insurance): Healthcare coverage for doctors' services, outpatient hospital care, and some other medical services that Part A does not cover, such as the services of physical and occupational therapists, and some home health care.
Medicare Summary Notice: A statement provided to patients or guardians by Medicare explaining how a claim was processed and paid.
Medicare Supplement: Insurance available by private insurance companies that pays for some services not covered by Medicare A or B, including deductible and coinsurance amounts.
Monthly Billing Statement: This is the QVMC bill.
Non-Covered Services: Services not covered under the patient's insurance plan. These charges are guarantor’s responsibility to pay.
Out-of-Network (OON): Services rendered by a provider which does not have a contract to offer you care. Typically, managed care plans are contracted with a panel of providers. If a patient seeks care out-of-network, they may be financially responsible for some or all of the care provided. An exception to this rule is emergency medical care.
Out-of-Pocket Costs: The amount that is paid by the patient or guarantor.
Point-of-Service (POS) Plans: An insurance plan that allows you to choose doctors and hospitals without first having to get a referral from your primary care physician.
Pre-Authorization: Authorization given by a health plan for a member to obtain services from a healthcare provider. This is commonly required for hospital services.
Pre-Certification Number: A number obtained from your insurance company by doctors and hospitals. This number will represent the agreement by the insurance plan that the service has been approved. This is not a guarantee of payment.
Preferred Provider Organizations (PPO): An insurance plan that has a contract with providers to provide healthcare services at a discounted rate.
- A patient may self-refer within a contracted network of physicians; after paying a deductible, a patient is commonly responsible for 10% or 20% of the allowable fee.
- A patient may choose to receive treatment from a provider outside of the PPO network thereby increasing his/her deductible or out-of-pocket maximum.
- The patient may be responsible for obtaining authorization from the health plan for some services such as physical therapy and MRI services.
- There is typically a lifetime policy maximum associated with PPO coverage.
Primary Care Physician (PCP): The primary care physician (can be an internist, pediatrician, family physician, or OB/GYN) is responsible for all general medical care of the patients and referrals to specialists for care when medically appropriate.
- Most HMO, EPO and POS plans require members to choose or be assigned to a primary care physician.
- The PCP is responsible for providing or authorizing all care (hospitalization, diagnostic, workups and specialty referrals) for that patient
- Depending on the type of insurance plan, a patient may not be covered for a visit to a specialist without prior approval of the primary care provider.
Primary Insurance Company: The insurance company primarily responsible for the payment of the claim.
Referral: Approval or consent by a primary care doctor for a patient to see a certain specialist or receive certain services.
Secondary Insurance: The insurance company responsible for the remainder of the claim after the primary insurance has determined benefits. If a patient has dual coverage, QVMC will file a claim for service with the secondary insurance.
Self-Payment or Self-Pay: If you do not have insurance, or if you are seeking care at QVMC outside of your insurance plan benefits, you are considered a self-pay patient. QVMC self-pay policy requires full payment within 30 days of billing.
Share of Cost (SOC): The amount a beneficiary must pay toward their health care costs before Medi-Cal will pay. The SOC may change when monthly income changes.
Subscriber: The person who is enrolled for benefits with an insurance company.
Supplemental Insurance: Insurance available by private insurance companies that pays for some services not covered by Medicare A or B, including deductible and coinsurance amounts.
Third Party Liability (TPL): Liability Insurance coverage becomes your primary insurance when an accident is the reason for your visit to QVMC. Patient accounting will make every effort to identify and coordinate coverage so your account is paid in a timely manner.
Worker’s Compensation: Worker Compensation provides insurance-type coverage for work-related illnesses and accidents. In order to use this insurance you must provide the appropriate insurance information, employer information, claim number and date of injury. This coverage is separate from regular medical coverage.