A
Allowable
The amount of money the insurance company approves for payment of the equipment to Tobii Dynavox. This amount almost never matches the amount Tobii Dynavox charges for the equipment. The client’s co-insurance is usually based on the insurance company’s allowable amount. For example, if the allowable amount is $5,000.00, and the client’s co-insurance is 10%, the amount the client will owe is $500.00. If however Tobii Dynavox is not a participating provider with the particular insurance company, the client’s amount due to Tobii Dynavox may be greater than the co-insurance amount.
C
Certificate of Medical Necessity (CMN)
This is usually a state-specific form which is signed by the physician or speech therapist.
Claim
Billing submitted to the insurance company after the equipment has been delivered.
Client Advocate
Person who is representing the client during the funding process. This person is usually a speech therapist or case manager.
Client Information Form
This is the form that is usually completed by a family member or other contact person. This form includes important information such as the client’s demographic information, physician information, the insurance information necessary for the funding department to process the funding request, and the shipping address where the client is requesting to have the equipment delivered.
CPT Code
Current Procedural Terminology. The code that describes the type of services that are being supplied. This is generally the same as a HCPC Code.
Custodial Care Facility
Facility that provides room, board and assistance with daily living activities, such as feeding and dressing. This care is generally provided on a long-term basis and does not entail the continuing attention of trained medical personnel.
D
Deductible
The amount that the client must pay annually before benefits will be paid by the insurance company.
Durable Medical Equipment (DME)
Services made for the treatment of a injury or disease that can withstand repeated use. Tobii Dynavox devices have been classified as Durable Medical Equipment.
E
Exclusions
Services for which the insurance company will not pay.
Explanation of Benefits (EOB)
Statement from the insurance company that shows the services and amounts that were paid by the policy. This is also know as a remittance.
H
HCPC
Code that is used to describe the services rendered. For example, the Tobii Dynavox I-12 has an HCPC code of E2510.
Hospice
Supportive care given to a terminally ill client and their family. The focus of this care is to enable the client to remain in the familiar surrounding of their home for as long as they can. Hospice care may be either inpatient or outpatient.
I
ICD-9 Code
International Classification of Diseases. Insurance code that describes a client’s medical condition or diagnosis.
Insurance Letter of Requirement (ILR)
This letter is sent to your insurance company by your funding coordinator and explains the details that should be included in a private insurance authorization. An approval form is also included with this letter. Insurance companies may complete the approval form instead of creating a letter.
Invoice
Itemized statement explaining what items or services have been delivered.
L
Letter of Medical Necessity (LMN)
A letter explaining the medical need for AAC services. This letter can be written by a physician, speech therapist or occupational therapist. These letters usually give the client’s diagnosis and a brief explanation of why services are necessary.
M
Managed Care Organization (MCO)
Any insurance plan in which the client will need to have services approved by their plan’s referring physician or medical group.
Maximum Out of Pocket
The maximum amount paid by the client before the insurance plan benefits will cover at the highest benefit level available in the plan. This may or may not include the deductible amount.
Medicaid
State-sponsored medical plan. Eligibility for these plans are traditionally based on a family’s income. May also be called Title 19.
Medicare
Federally-sponsored medical plan. Clients become eligible for this program when they turn age 65 or have a qualifying disability. There are 2 separate programs under Medicare: Part A (hospitalization) and Part B (medical). Clients must pay a monthly fee for Part B coverage. Tobii Dynavox devices are covered under Medicare Part B.
Medicare Supplement
An insurance policy that covers Medicare co-insurance and other services. This policy must be purchased by the Medicare beneficiary.
N
NPI
National provider identifier (NPI) is a unique ten-digit identification number required by HIPAA for all health care providers in the United States . Providers must use their NPI to identify themselves in all HIPAA transactions.
O
Original Documentation
Prescription and speech evaluation that has an original signature. The signature page on the evaluation and the doctor’s prescription cannot be copied or faxed. Medicare requires that original documentation be on file at Tobii Dynavox for any product.
P
Place of Service (POS)
Location where the medical services will be provided or used. It is important that we know whether a client lives at home, in a group home or in a nursing facility. Some funding sources will not cover clients that live in a nursing facility.
Pre-certification
See Prior Authorization.
Pre-determination
Review done by an insurance company to determine whether a service will be considered a covered benefit.
Prior Authorization
Approval issued by the insurance company before equipment is delivered. Authorizations are normally issued by nurse reviewers at the insurance company who review the doctor’s orders and other documentation to ensure that a service is medically necessary.
R
Referral
Specific directions or instructions from a client’s primary care physician. Referrals may be on paper or electronic, and are usually required by HMO policies.
Release of Information Form
Form that is signed by a client and/or their guardian that allows Tobii Dynavox to exchange the required benefit, authorization and billing information with the insurance company that is necessary to process the funding for the equipment. Without this signed form Tobii Dynavox would not be permitted to collect or release any of your insurance information.
Remittance
Statement sent to medical providers from the insurance company to show the payment that was issued. Also called Explanation of Benefits (EOB).
Rx
Prescription.
S
Skilled Nursing Facility (SNF)
Facility which provides inpatient skilled nursing care and related services to patients who require medical, nursing or rehabilitative services but do not require the level of care provided in a hospital. If a person is in this type of facility, they are not able to use Medicare as a funding source.
Sole Supplier
Provider who is the only source of services or equipment. For example, Tobii Dynavox is the sole supplier of the Tobii Dynavox T7. Many insurance companies will authorize at a higher level when informed that a company is a sole provider.
Stop Loss
See Maximum Out of Pocket.
Subscriber
Employee covered under an employer’s group insurance policy. Also referred to as the policy holder.
T
TRICARE
Health insurance program for military personnel and their families.
U
Usual and Customary Charges
Also referred to as Reasonable and Customary Charge. An amount determined by an insurance company that represents a routine charge for a medical service by similar medical and professional providers in the same geographical area. Allowable amounts are normally based on the Usual and Customary Charge.
