US Healthcare Terminology -Basics for Healthcare Business.

The first one is subscriber. So a subscriber is an individual who, who meets the health plans, eligibility requirement, and who can enroll in a health plan, and he or she accepts the financial responsibility for any premiums or CO payments coinsurance or deductibles.
So the next term is a member, member is a person who is eligible to receive or is receiving benefits from an HMO or an insurance policy. This This includes those who have enrolled or subscribed in their eligible dependents, so a subscriber is the person who gets these benefits, whereas a member gets enrolled and also his, his dependents are covered so person becomes a member of a health care plan, whereas a subscriber is just an individual.
The next term is provider, so a provider is a supplier of healthcare services, like a hospital or nursing home lab or physician so anyone who provides you with the healthcare service is called the provider.
The next one is claim. So a claim is, is like a detail invoice that your healthcare provider so like we talked about in the earlier from a doctor or a clinic or hospital, this, this claim is like an invoice that’s, that’s being sent to the health insurance, health insurer, who is your insurance provider and this invoice will exactly show what services you have received your member ID, your name your demographics, everything that’s needed to actually pay out that claim.
And next is co insurance. So, coinsurance, you might have come across this term, this is a form of cost sharing between the member and the insurance company so you and the health insurance provider. So, if you’re insured, you pay a percentage of the cost of covered medical services, and the insurance company pays a percentage. So usually it’s like after you cross a certain amount of money, and after you pay it out. The insurance company won’t usually pay you the entire amount of money. It’s like will pay 90% And you have to cover the remaining 10% Now I want to include another word here it’s called out of pocket maximum. So, for example the out of pocket maximum is like $10,000, you are only liable to pay $10,000 So, if your claim amount is $20,000. The 10 percentage that I mentioned earlier, would be applicable only for the $10,000 out of pocket maximum. After that, the claim, usually covers the entire charges that you have to incur.
The next one is CO payment. SO, CO payment again is a form of cost sharing where the insured person basis specify specified flat amount per unit of service, so for example if you’re visiting a doctor and the doctor charges 200 bucks. The CO payment is going to be $30, so you only pay $30 The remaining $70 is being taken care of by the health insurance that you have.
And the next one is deductible. So A deductible is a certain dollar amount that you must pay before your health insurance coverage, actually begins to cover your medical expenses.
It might be $500 per year. And once you’ve got across the $500.
Then the coinsurance applies for applicable, and the plan then proceeds.
Now, getting a bit more technical. So the next word is EDI. This definition is electronic data interchange. Now this is applicable in different industries. And basically this is just a computer to computer exchange of business documents in a standard electronic format, between business partners. So basically it’s an encrypted way of sending information from one organization to another, because the data that you’re transmitting is sensitive.
The next term is going to be personal health information or PHI .this is also referred to as protected health information. So this generally refers to demographic information like your age, your location, your first name, your last name, your medical history the test and lab results, the insurance information, and any other data that a healthcare professional, collects to identify an individual and determine appropriate care. Now, this is protected information because this is confidential and is shouldn’t be only accessible by you.
So when you’re transmitting this information from one organization to another, they make sure that that it’s encrypted and it doesn’t get leaked.
The next one is going to be HIPAA, so HIPAA is Health Insurance Portability and Accountability Act of 1996 because that was the year that it was introduced. So HIPAA is nothing but a law that sets standards regarding the security and privacy of a person’s health information.
This has several titles, but we’re just going to talk about Title One and title two, because these titles are more apply more to healthcare claims processing. So, the first title is called health insurance reform. Now, this is a title that protects health insurance coverage for individuals who lose or change jobs. So suppose you lose your job, or change your job. The diamond trouble should be covered by your health insurance. And this also prohibits on group health plans from denying coverage to individuals with specific diseases and pre existing conditions, and from setting lifetime coverage limits. So that basically means that if you have a pre existing condition, that should be covered by your health insurance plan and that is the law.
Moving on to title one to title two is administrative simplification. So, this title basically says that it establishes national standards for processing these health insurance transactions. So it basically requires your health care organizations to implement the secure systems to transmit this health data from one organization to another or to the state.
The next term is coordination of benefits. So, this is a process where, if an individual has to group health plans, the amount payable is divided between the two plans. So, the combined coverage amounts. Do not exceed 200% of the charges. So it’s basically means that if the person has two plans, it shouldn’t be more than 100% of what the person should be actually getting the next one is ICD codes.
So, we’re going to talk about ICD 10 First, so I think he just means International Classification of Diseases. And previously, the version was ICD nine. After the October 1 of 2015, ICD, 10 was introduced and it’s basically a clinical cataloguing system that went into effect. And this basically accounts for modern advances in clinical treatment and medical devices. So, these codes actually offer many forms of classifying options compared to ICD nine. So, ICD 10 actually covers about 16,000 medical devices and healthcare health conditions, whereas ICD nine covers about 13,000 and the next term is HL7. It provides a framework. It’s help level seven, and this provides a framework where the exchange, the sharing and retrieval of electronic health information.
This has been this basically follows a certain structure and the standards are basically how information is defined and communicated from one party to another. So it sets, what language to use what the data structure of the file should be what, what the data types should be. So this basically helps the integration between different systems.
The last one is ASC X12, So ASC X12 is a file created by standards committee. So, it’s an organization, and it was charted by the American National Standards Institute and develops and maintains these xml content, and establishes standards for. So, These EDI files are basically XML schemas and the organization or committee. They actually need to remind how these standards should be called the file structure.


Department of Public Health, State of Massachusetts. An Act Providing Access to Affordable, Quality, Accountable Health Care 2006.
National Health Expenditure Data. Centers for Medicare & Medcaid Services web- site.
-Reports/NationalHealthExpendData/index.html. Accessed May 17, 2021.
Murray CJ, Frenk J. A framework for assessing the performance of health systems.
Bull World Health Organ. 2000;78(6):717–731.
OECD. Performance measurement and improvement in OECD health systems: over- view of issues and challenges. In: Measuring Up: Improving Health System Performance in OECD Countries. Paris, France: OECD Publishing; 2002.
OECD. Health status: infant mortality. In: Health at a Glance 2011: OECD Indica- tors. Paris, France: OECD Publishing; 2011.
Anderson GF, Markovich P. Multinational comparisons of health systems data, 2008. Commonwealth Fund website.
/Chartbooks/2010/Apr/Multinational-Comparisonsof-Health-Systems-Data-2008.aspx. Published 2008. Accessed March 31, 2021.
OECD. Health status: life expectancy at birth. In: Health at a Glance 2011: OECD Indicators. Paris, France: OECD Publishing; 2011.
OECD. Quality of care: avoidable admissions—respiratory diseases. In: Health at a Glance 2011: OECD Indicators. Paris, France: OECD Publishing; 2011.
OECD. Health expenditure and financing: health expenditure in relation to GDP. In:
Health at a Glance 2011: OECD Indicators. Paris, France: OECD Publishing; 2011.
OECD. Health expenditure and financing: health expenditure per capita. In: Health at a Glance 2011: OECD Indicators. Paris, France: OECD Publishing; 2011.
DeNavas-Walt C, Proctor BD, Smith JC, U.S. Census Bureau. Current Population Reports (P60-239): Income, Poverty, and Health Insurance Coverage in the United States: 2010. Washington, DC: U.S. Govenrment Printing Office; 2011.
The Patient Protection and Affordable Care Act. 111th Congress, 2nd Session, ed 2010.
NHE summary including share of GDP, CY 1960–2010; Historical National Health Expenditure Data. Centers for Medicare & Medicaid Services website. -Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html. Accessed April 9, 2021.
U.S. Census Bureau. Projections of the population and components of change for the United States: 2010 to 2050. Accessed March 31, 2021.
NHE Historical and projections, 1965–2020; Projected National Health Expendi- ture Data. Centers for Medicare & Medicaid Services website.
/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/National HealthExpendData/NationalHealthAccountsProjected.html. Accessed April 9, 2021.
CBO’s Year-by-Year Forecast and Projections for Calendar Years 2009 to 2020; The Budget and Economic Outlook: Fiscal Years 2010 to 2020. Congressional Budget Office website. Accessed April 9, 2021.
Orszag PR. CBO testimony: growth in health care costs. Delivered before the Com- mittee on the Budget, United States Senate. Washington, DC: Congressional Budget Office; 2008.
Congressional Budget Office. CBO’s economic projections for 2009 to 2019. http:// Accessed March 31, 2021.
Mitka M. Growth in health care spending slows, but still outpaces rate of inflation.
JAMA. 2009;301(8):815–816.
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