Health Insurance Abbreviations
107 abbreviations · part of Medical Abbreviations
Abbreviations found on insurance cards, benefit summaries, explanation of benefits statements, medical bills and enrollment forms, including US plan types, tax-advantaged health accounts, Medicare and Medicaid programs, billing code sets, claim forms and health care payment and privacy rules. Dollar limits and enrollment dates change every year and differ by plan, so figures are given as examples for the year stated; current details come from plan documents, HealthCare.gov, Medicare.gov or the IRS.
| Abbreviation | Stands for | Description |
|---|---|---|
| ABN | Advance Beneficiary Notice of Noncoverage | Medicare form (CMS-R-131) given to Original Medicare patients before a service Medicare may not cover, stating the expected cost so the patient can decide whether to… |
| ACA | Affordable Care Act | US health reform law signed March 23, 2010, formally the Patient Protection and Affordable Care Act and widely called Obamacare. |
| ACO | Accountable care organization | Group of doctors, hospitals and other providers that voluntarily share responsibility for the quality and total cost of care for a defined population, earning a share… |
| AEP | Annual Enrollment Period | Medicare's fall window, October 15 to December 7 each year, when beneficiaries can switch between Original Medicare and Medicare Advantage, change Medicare Advantage… |
| AOB | Assignment of benefits | Authorization in which a patient directs an insurer to pay a provider directly instead of reimbursing the patient. |
| APC | Ambulatory payment classification | Groups of clinically similar outpatient hospital services with similar costs, each assigned a payment rate under Medicare's Outpatient Prospective Payment System. |
| APTC | Advance premium tax credit | Subsidy for health insurance bought through an ACA marketplace that is paid in advance each month directly to the insurer to lower the enrollee's premium. |
| ASO | Administrative services only | Arrangement in which an insurance company provides claims processing, network access and other administrative services to a self-funded employer for a fee, while the… |
| AV | Actuarial value | Percentage of average total costs for covered benefits that a health plan pays, used under the Affordable Care Act to sort individual and small-group plans into metal… |
| BAA | Business associate agreement | Contract required under HIPAA between a covered entity, such as a hospital, health plan or physician practice, and a vendor that creates, receives, stores or transmits… |
| BCBS | Blue Cross Blue Shield | Federation of more than 30 independent, locally operated health insurance companies licensed by the Blue Cross Blue Shield Association, together covering about one in… |
| CDHP | Consumer-directed health plan | Plan design pairing a high deductible with a tax-advantaged account, such as an HSA or HRA, that members use to pay for care, giving them more control over spending and… |
| CDM | Charge description master (chargemaster) | Hospital's master list of billable items with their list prices, from room charges and procedures to individual supplies and drugs, each linked to the codes used on… |
| CHIP | Children's Health Insurance Program | Joint federal-state program that provides low-cost health coverage to children, and in some states pregnant women, in families that earn too much to qualify for… |
| CMS | Centers for Medicare & Medicaid Services | Federal agency within the US Department of Health and Human Services that runs Medicare, works with states on Medicaid and CHIP, oversees the federal health insurance… |
| CMS-1500 | CMS-1500 claim form | Standard paper claim form used by physicians, other professionals and suppliers to bill Medicare, Medicaid and most private insurers for professional services. |
| COB | Coordination of benefits | Rules deciding which health plan pays first when a person has more than one source of coverage, such as two employer plans, Medicare plus employer coverage, or auto… |
| COBRA | Consolidated Omnibus Budget Reconciliation Act | US law of 1985 that lets employees and their families keep employer group health coverage temporarily after job loss, reduced hours, divorce or other qualifying events. |
| CPT | Current Procedural Terminology | Five-character code set, owned and maintained by the American Medical Association, used to report medical, surgical, radiology, laboratory and other services on US… |
| CSR | Cost-sharing reduction | Extra savings on deductibles, copays and out-of-pocket maximums for lower-income people who enroll in a silver plan on an ACA marketplace, generally those with incomes… |
| DCFSA | Dependent care flexible spending account | Employer account for pre-tax payment of care for children under 13 or dependent adults so that the account holder can work, covering day care, preschool, summer day… |
| DRG | Diagnosis-related group | Classification of hospital inpatient stays into groups with similar clinical characteristics and expected resource use, which sets a fixed payment per admission under… |
| EHB | Essential health benefits | Ten categories of services that ACA-compliant individual and small-group plans must cover: outpatient care, emergency services, hospitalization, maternity and newborn… |
| EOB | Explanation of benefits | Statement sent by a health insurer after a claim is processed, showing the service, the amount billed, the plan's allowed amount, what the plan paid and what the… |
| EOC | Evidence of coverage | Detailed legal document describing what a health plan covers, what members pay, the rules for using the network and how to appeal, used particularly for Medicare… |
| EPO | Exclusive provider organization | Plan type that, like an HMO, covers only in-network care except in emergencies, but like a PPO usually does not require a primary care physician or referrals to see… |
| ERA | Electronic remittance advice | Electronic explanation of payment that insurers send to providers, detailing how each claim was paid, adjusted or denied, in the standard HIPAA X12 835 transaction. |
| ERISA | Employee Retirement Income Security Act | Law of 1974 setting minimum standards for most private-sector retirement and health plans, including fiduciary duties for those who manage plan money, vesting and… |
| ESI | Employer-sponsored insurance | Health coverage offered through an employer or union, the largest source of health insurance in the United States, covering roughly half of the population. |
| FEHB | Federal Employees Health Benefits (Program) | Health insurance program for US federal civilian employees, retirees and their families, administered by the Office of Personnel Management and offering a choice among… |
| FFS | Fee-for-service | Payment model in which providers are paid separately for each visit, test or procedure. |
| FPL | Federal poverty level | Income measure, based on annual HHS poverty guidelines, used to determine eligibility for programs such as Medicaid, CHIP, ACA subsidies, SNAP and school meals. |
| FSA | Flexible spending account | Employer-sponsored account funded through pre-tax payroll deductions and used for eligible out-of-pocket health costs such as copays, eyeglasses and prescriptions. |
| FWA | Fraud, waste and abuse | Umbrella term used by Medicare, Medicaid and health plans for improper billing and spending, from intentional fraud such as billing for services never provided, to… |
| GFE | Good faith estimate | Written estimate of expected charges that US providers must give uninsured and self-pay patients before scheduled care, or on request, under the No Surprises Act. |
| HCC | Hierarchical condition category | Groups of related diagnosis codes used in the CMS risk adjustment model to predict each Medicare Advantage enrollee's expected costs. |
| HCPCS | Healthcare Common Procedure Coding System | Two-level US coding system for billing: Level I is the AMA's CPT code set, and Level II consists of alphanumeric codes (a letter followed by four digits) for products… |
| HDHP | High-deductible health plan | Plan with a deductible at or above a minimum set by the IRS, which makes the enrollee eligible to contribute to a health savings account. |
| HEDIS | Healthcare Effectiveness Data and Information Set | Set of more than 90 standardized performance measures, maintained by NCQA, that most US health plans use to report quality of care, such as rates of breast cancer… |
| HIPAA | Health Insurance Portability and Accountability Act | US law of 1996 that protects health coverage when people change jobs, standardizes electronic health care transactions and codes, and, through its Privacy and Security… |
| HMO | Health maintenance organization | Managed care health plan that covers care only from its network of doctors and hospitals, except in emergencies, and usually requires members to choose a primary care… |
| HRA | Health reimbursement arrangement | Employer-funded account that reimburses employees tax-free for qualified medical expenses and, in some designs, insurance premiums. |
| HSA | Health savings account | Tax-advantaged account paired with a high-deductible health plan that lets the holder pay qualified medical costs with pre-tax money. |
| ICD | International Classification of Diseases | World Health Organization standard for classifying diseases, injuries, symptoms and causes of death, used worldwide for mortality statistics and health records and, in… |
| ICD-10 | International Classification of Diseases, Tenth Revision | Tenth revision of the WHO disease classification, endorsed in 1990 and used internationally from the mid-1990s. |
| ICD-10-CM | ICD-10 Clinical Modification | US version of ICD-10 used to code diagnoses in all health care settings, maintained by the CDC's National Center for Health Statistics. |
| ICD-10-PCS | ICD-10 Procedure Coding System | US system for coding inpatient hospital procedures, maintained by CMS, in which every code has exactly seven alphanumeric characters describing section, body system… |
| ICD-11 | International Classification of Diseases, Eleventh Revision | Latest WHO revision of the disease classification, adopted by the World Health Assembly in 2019 and in effect for international reporting since January 1, 2022. |
| ICHRA | Individual coverage health reimbursement arrangement | Employer-funded HRA, available since 2020, that reimburses employees tax-free for individual health insurance premiums and medical expenses instead of offering a group… |
| IDR | Independent dispute resolution | Federal arbitration process under the No Surprises Act for settling payment disputes between out-of-network providers and health plans after open negotiation fails. |
| IEP | Initial Enrollment Period | Seven-month window around a person's 65th birthday (the three months before, the birthday month and the three months after) when they can first sign up for Medicare… |
| IME | Independent medical examination | Examination of a claimant by a physician chosen by the opposing party or insurer to evaluate injuries, causation, disability or need for treatment. |
| IPA | Independent practice association | Network of independent physicians or medical groups that contracts collectively with health plans, especially HMOs, while members keep their own private practices. |
| IPPS | Inpatient Prospective Payment System | Medicare's method of paying acute care hospitals a predetermined amount per inpatient stay based on the MS-DRG, adjusted for local wages, teaching status, a high share… |
| IRMAA | Income-Related Monthly Adjustment Amount | Surcharge added to Medicare Part B and Part D premiums for higher-income beneficiaries, based on modified adjusted gross income from the tax return two years earlier. |
| LCD | Local coverage determination | Decision by a Medicare Administrative Contractor about whether a service is reasonable and necessary, and therefore covered, in its jurisdiction, often listing… |
| LIS | Low-Income Subsidy (Extra Help) | Federal program that helps people with limited income and resources pay Medicare Part D premiums, deductibles and copays. |
| LPFSA | Limited-purpose flexible spending account | FSA restricted to dental and vision expenses, designed so people with a health savings account can still use pre-tax FSA dollars. |
| LTCI | Long-term care insurance | Private insurance that helps pay for extended custodial care, such as help with bathing and dressing at home, in assisted living or in a nursing home, which health… |
| MA | Medicare Advantage | Private health plans approved by Medicare that provide Part A and Part B benefits, usually with prescription drug coverage and extras such as dental and vision. |
| MAC | Medicare Administrative Contractor | Private health insurer contracted by CMS to process Medicare Part A and Part B claims, or durable medical equipment claims, for a geographic jurisdiction. |
| MACRA | Medicare Access and CHIP Reauthorization Act | Federal law of 2015 that repealed Medicare's sustainable growth rate formula for physician payments and created the Quality Payment Program, with its MIPS and advanced… |
| MAGI | Modified adjusted gross income | Income measure used to determine eligibility for ACA premium tax credits, Medicaid for most adults and children, and various tax benefits. |
| MAPD | Medicare Advantage Prescription Drug plan | Medicare Advantage plan that bundles Part D prescription drug coverage with medical benefits, the most common form of Medicare Advantage. |
| MCO | Managed care organization | Health plan that delivers care through contracted networks and manages cost and quality with tools such as primary care gatekeepers, prior authorization and negotiated… |
| MEC | Minimum essential coverage | Type of health coverage that satisfied the Affordable Care Act's individual mandate, including employer plans, marketplace plans, Medicare Part A, most Medicaid, CHIP… |
| MIPS | Merit-based Incentive Payment System | Medicare program that adjusts clinicians' Part B payments up or down according to performance in four categories: quality, cost, improvement activities and promoting… |
| MLR | Medical loss ratio | Share of premium revenue an insurer spends on medical claims and quality improvement rather than administration and profit. |
| MOOP | Maximum out-of-pocket | Annual cap on what a member pays for covered services, a term used especially for Medicare Advantage plans, which must limit enrollee cost sharing for Medicare-covered… |
| MPFS | Medicare Physician Fee Schedule | List of payment amounts Medicare uses to pay physicians and other practitioners for more than 10,000 services, calculated from relative value units, geographic… |
| MS-DRG | Medicare Severity Diagnosis-Related Group | Version of DRGs used by Medicare since fiscal year 2008, which splits many groups into tiers according to whether the patient has a major complication or comorbidity… |
| MSP | Medicare Savings Program | State-run Medicaid programs that help people with limited income and assets pay Medicare costs. |
| NCCI | National Correct Coding Initiative | CMS program, begun in 1996, that publishes automated edits to prevent improper payment when codes are billed together incorrectly. |
| NCD | National coverage determination | Medicare decision, made by CMS through a public process, on whether a specific item or service is covered nationwide and under what conditions. |
| NCQA | National Committee for Quality Assurance | Independent nonprofit founded in 1990 that accredits health plans, recognizes medical practices such as patient-centered medical homes and develops the HEDIS quality… |
| NPI | National Provider Identifier | Unique 10-digit number issued by CMS to US health care providers and organizations and required on standard electronic claims under HIPAA. |
| NSA | No Surprises Act | US federal law, effective January 1, 2022, protecting privately insured patients from surprise medical bills for emergency care, for non-emergency care by… |
| OEP | Open enrollment period | Annual window during which people can enroll in, change or drop health coverage without a qualifying life event, used by ACA marketplaces and employer plans. |
| OON | Out-of-network | Describes providers or facilities without a contract with a patient's health plan, so the plan pays less or nothing for their services and the patient may face higher… |
| OOP | Out-of-pocket | Health care costs paid by the patient rather than the insurer, such as deductibles, copays and coinsurance, plus services the plan does not cover. |
| OPPS | Outpatient Prospective Payment System | Medicare's payment system for hospital outpatient services, such as emergency visits, outpatient surgery, imaging and clinic visits, which groups services into… |
| PACE | Program of All-Inclusive Care for the Elderly | Medicare and Medicaid program providing comprehensive medical and social services to frail older adults who qualify for nursing home care but can live safely in the… |
| Par | Participating (provider) | Billing shorthand for a provider who has a contract with a health plan or who has agreed to accept Medicare assignment on all claims. |
| PDP | Prescription drug plan (Medicare Part D) | Stand-alone Medicare Part D plan sold by private insurers to add outpatient prescription drug coverage to Original Medicare. |
| PHI | Protected health information | Individually identifiable health information held or transmitted by a HIPAA covered entity or business associate, in any form, relating to a person's health, care or… |
| PIP | Personal injury protection | Auto insurance coverage that pays medical expenses, lost wages and sometimes funeral and household services for the driver and passengers after an accident, regardless… |
| PMPM | Per member per month | Standard unit for expressing health plan costs, premiums and capitation payments, calculated by dividing total dollars by the number of enrolled members in each month. |
| POS | Point of service (plan) | Hybrid managed care plan combining HMO and PPO features: members choose a primary care physician and need referrals, but can go out of network at higher cost. |
| PPO | Preferred provider organization | Health plan with a network of contracted providers that offers lower costs in-network but still pays part of the cost of out-of-network care, and usually lets members… |
| QHP | Qualified health plan | Health plan certified for sale on an ACA marketplace, meeting requirements for essential health benefits, cost-sharing limits, network adequacy and metal tiers. |
| QMB | Qualified Medicare Beneficiary | Medicare Savings Program for people with the lowest incomes that pays Medicare Part A and B premiums, deductibles, coinsurance and copays. |
| QSEHRA | Qualified small employer health reimbursement arrangement | HRA for employers with fewer than 50 full-time employees that do not offer a group plan, letting them reimburse workers tax-free for individual insurance premiums and… |
| RAC | Recovery Audit Contractor | Private company paid by CMS on a contingency-fee basis to identify and recover improper Medicare fee-for-service payments, both overpayments and underpayments. |
| RAF | Risk adjustment factor | Numerical risk score for a health plan member, calculated from demographics and documented diagnoses, that scales capitated payments to the expected cost of care. |
| RVU | Relative value unit | Measure used in Medicare's physician fee schedule to value services, combining three components: physician work, practice expense and malpractice insurance cost. |
| SBC | Summary of benefits and coverage | Standardized document, required by the Affordable Care Act, that summarizes a health plan's costs and coverage in a uniform format so consumers can compare plans side… |
| SEP | Special enrollment period | Window outside the annual open enrollment period during which a person can sign up for or change health coverage after a qualifying life event, such as losing other… |
| SHIP | State Health Insurance Assistance Program | Federally funded network of state programs offering free, unbiased one-on-one counseling about Medicare, Medicare Advantage, Medigap, Part D and related benefits. |
| SHOP | Small Business Health Options Program | ACA marketplace for small employers, generally those with 1 to 50 employees (up to 100 in some states), to offer qualified health plans to their workers. |
| SNP | Special needs plan | Medicare Advantage plan limited to people with particular needs: those eligible for both Medicare and Medicaid (D-SNP), people with certain chronic conditions such as… |
| SPD | Summary plan description | Plain-language document that ERISA requires employer benefit plans to give participants, explaining coverage, how benefits work, eligibility, claims and appeals… |
| TPA | Third-party administrator | Company that handles administrative work for self-funded employer health plans, such as processing claims, managing enrollment, providing customer service and arranging… |
| UB-04 | Uniform Bill 2004 (CMS-1450 claim form) | Standard claim form used by hospitals, nursing facilities, home health agencies and other institutional providers to bill for inpatient and outpatient services. |
| UCR | Usual, customary and reasonable | Amount an insurer considers the normal charge for a service in a geographic area, used to calculate out-of-network payments. |
| UHC | UnitedHealthcare | Health insurance business of UnitedHealth Group, the largest US health insurer by revenue and membership, offering employer, individual, Medicare Advantage and Medicaid… |
| VBC | Value-based care | Health care payment and delivery approach that rewards providers for quality, outcomes and cost efficiency rather than the volume of services. |
| WC | Workers' compensation | Insurance employers buy, required in nearly every US state, that pays medical care, lost wages, rehabilitation and death benefits to employees injured or made ill by… |
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