Lien and billing glossary

Assignment of benefits

A form where a patient lets a provider bill and collect insurance benefits directly. It is about insurance payments. It is different from a lien or a letter of protection.

Balance billing

When a provider bills the patient for the part of a charge that insurance did not pay. Whether it is allowed depends on the contract and the situation. Ask the attorney before a client is told anything.

CPT code

A five-digit code that names a medical service on a bill, such as an office visit or an MRI. Itemized bills list one CPT code per line.

CMS-1500

The standard claim form many outpatient providers use to bill insurance. Providers sometimes send a copy with a bill request.

Co-pay

A fixed amount a patient with insurance pays for a visit. Co-pays are separate from a lien.

Conditional payment (Medicare)

An amount Medicare paid for care that it may later ask to be repaid out of a settlement. The attorney handles that process.

Custodian of records

The person at a provider’s office responsible for medical or billing records. When you request records, this is often who you need to reach.

Deductible

The amount a patient pays before insurance starts to pay. A high deductible is one reason clients delay care.

Demand package

The set of documents the attorney sends to the insurer to support a claim: records, bills, a timeline and other proof. The attorney decides what goes in.

Disbursement

The step where settlement money is divided and paid out, including payments to lien holders. The attorney’s office controls it.

Explanation of benefits (EOB)

A statement from a health plan that shows what a provider charged, what the plan paid and what the patient may owe. It is not a bill.

Gap in treatment

A stretch of time with no visits between treatment dates. Insurers may ask about gaps, so case managers track them and note the reason the client gives.

Health plan lien

A claim by a health plan to be repaid from a settlement for care it paid for. The attorney handles these.

HIPAA authorization

A signed form that lets a provider release a patient’s records to a named person or firm. Providers usually will not release records without one.

ICD-10 code

A code that names a diagnosis on a medical record or bill. Do not interpret these yourself. Pass questions to the provider.

Independent medical exam (IME)

An exam by a doctor chosen by the other side, not the patient’s own provider. The attorney handles scheduling and prep.

Itemized bill

A bill that lists each service with its date, code and charge. A summary or a total alone is not itemized.

Letter of protection (LOP)

A letter from the firm that tells a provider the client wants care now and the provider will be paid from any recovery. The exact terms vary, so use the firm’s own form.

Lien

A claim on money a client may recover in a case. A provider with a lien is paid from the recovery rather than up front.

Lien holder

The provider, plan or agency that has a lien. You will need the right contact for each one.

Lien reduction

A request that a lien holder accept less than the full balance. The attorney leads this. You help by gathering balances and contacts.

Maximum medical improvement (MMI)

A point where a provider says the patient is not expected to improve much more. Only the provider says whether a patient has reached it.

Medi-Cal lien

A claim by the state’s Medi-Cal program to be repaid from a settlement for care it paid for. The attorney handles it.

Medical funding company

A company that buys a provider’s bills and then collects from the recovery. Ask the provider’s office who now holds the balance.

Narrative report

A letter from a treating provider that explains the patient’s care in plain sentences. The attorney decides when to ask for one.

Out-of-network

A provider that does not have a contract with the patient’s health plan. This affects how bills are handled.

Payoff letter

A written statement of what a lien holder says is owed on a certain date. Ask the attorney which lien holders need one and when.

Policy limits

The most an insurance policy will pay. The attorney finds and uses these. Case managers should not guess them.

Pre-existing condition

A health problem the patient had before the incident. Tell the attorney early if a client mentions one.

Records request

A written request, usually with a signed authorization, asking a provider for medical or billing records.

Settlement

An agreement that ends a claim for a set amount of money. The attorney handles every step.

Subpoena for records

A formal legal demand for records. The attorney handles these. If a provider’s office mentions one, tell the attorney.

Treating provider

A doctor, therapist or other provider who is actually treating the client, as opposed to one hired only to review a file.

UB-04

The standard claim form hospitals and facilities use for billing. It is often part of a hospital bill request.

Usual and customary

A phrase for what providers normally charge, or what is normally paid, for a service in an area. How it is measured is a billing and legal question. Ask the attorney how it applies.

No terms match. Try a shorter word.

Definitions are general and written for office staff. They are not legal advice. Ask the attorney how a term applies to a specific file. For Spanish handouts and a law-office glossary, see the For Law Offices glossary.