Balance billing

The practice of billing a patient for the fee amount remaining after insurer payment and co-payment have been made. Under Medicare, the excess amount cannot be more than 15 percent above the approved charge.

Beneficiary (Also eligible; enrollee; member)

Individual who is either using or eligible to use insurance benefits, including health insurance benefits, under an insurance contract. Any person eligible as either a subscriber or a dependent for a managed care service in accordance with a contract. An individual who receives benefits from or is covered by an insurance policy or other health care financing program.

Benefit Limitations

Any provision, other than an exclusion, which restricts coverage in the Evidence of Coverage, regardless of medical necessity

Benefit Package

Aggregate services specifically defined by an insurance policy or HMO that can be provided to patients. The services a payer offers to a group or individual.

Benefit Payment Schedule

List of amounts an insurance plan will pay for covered health care services.

Benefits

Benefits are specific areas of Plan coverage's, i.e., outpatient visits, hospitalization and so forth, that make up the range of medical services that a payer markets to its subscribers. Also, a contractual agreement, specified in an Evidence of Coverage, determining covered services provided by insurers to members.

Billed Claims

Fees submitted by a health care provider for services rendered to a covered person.

Board Certified (Boarded, Diplomate)

Describes a physician who has passed a written and oral examination given by a medical specialty board and who has been certified as a specialist in that area.

Board Eligible

Describes a physician who is eligible to take the specialty board examination by virtue of being graduated from an approved medical school, completing a specific type and length of training, and practicing for a specified amount of time. Some HMOs and other health facilities accept board eligibility as equivalent to board certification, significant in that many managed care companies restrict referrals to physicians without certification.

Bundled Payment

A single comprehensive payment for a group of related services. Bundled payments have become the norm in recent years and unbundled services are investigated closely by HCFA and other payers. Unbundling service charges has been a common form of fraud as defined by HCFA.

Broker

One who represents an insured in solicitation, negotiation, or procurement of contracts of insurance, and who may render services incidental to those functions. By law, the broker may also be an agent of the insurer for certain purposes such as delivery of the policy or collection of the premium.