Medical billing glossary

Authorisation (pre-authorisation)

Approval from a medical scheme before a planned admission or procedure, with an authorisation number that should appear on the account.

Age analysis

A report that groups outstanding accounts by how long they have been unpaid, used to prioritise follow-up.

Benefit option

The plan a member is on within a medical scheme. Benefits, networks and rules differ between options.

CDL (Chronic Disease List)

The list of chronic conditions that schemes must cover as part of Prescribed Minimum Benefits.

Co-payment

An amount the member must pay themselves, set by the scheme rules, for example for certain procedures or for not using a network provider.

Dependant code

The code that identifies which person on a scheme membership received the service. A wrong dependant code is a common cause of rejection.

DSP (Designated Service Provider)

A provider or network chosen by a scheme to treat its members, often for PMBs. Using a non-DSP can lead to a co-payment.

EDI (electronic data interchange)

Electronic submission of claims to medical schemes, usually through a claims switching house.

Gap cover

Short-term insurance that may pay the difference between a specialist’s fee and what the scheme pays for in-hospital services, according to the policy.

ICD-10

The international classification of diseases used in South Africa to code diagnoses on claims.

Informed financial consent

Telling the patient in advance what a procedure will cost and what they may have to pay themselves.

Modifier

A code added to a procedure code to show a special circumstance, such as multiple procedures or an assistant.

Patient portion (shortfall)

The part of an account that the scheme doesn’t pay and the patient owes.

PMB (Prescribed Minimum Benefits)

Conditions and treatments that schemes must cover under the Medical Schemes Act, subject to scheme rules such as DSPs and protocols.

Practice number

The number that identifies a practice for billing. Each practitioner who bills, including assistants and anaesthetists, uses their own.

Reconciliation

Matching scheme remittances and bank deposits to the accounts they pay, so balances are correct.

Rejection

A claim the scheme returns unpaid, with a reason. Many can be corrected and resubmitted.

Remittance advice

The scheme’s statement of what it paid, short-paid or rejected on each claim.

Short payment

A claim paid at less than the amount billed, for example at the scheme’s rate.

Stale claim

A claim submitted too late. Claims generally have to be submitted by the end of the fourth month after the month of service.

Switching house

The service that routes electronic claims between practices or bureaus and medical schemes.

Tariff code

The code that identifies the procedure or service billed, linked to a fee.

More in the billing guide and specialty pages.