Balance Billing The practice of charging full fees in excess of covered amounts, then billing the patient for that portion of the bill that the payor does not cover.

Balance Billing Limit A Medicare regulation that limits the maximum fee that a non-participating physician may charge a Medicare beneficiary to 115% above the Medicare-approved amount. The physician is prohibited from collecting the difference or balance between his/her regular fee and the balance billing limit.

Beneficiary Term used to identify any individual eligible for Medicare benefits.

Benefit Period For an inpatient hospital/skilled nursing facility (SNF), this is a period of time starting on the first day that a beneficiary is admitted to a qualified inpatient hospital and ending when he/she has not been an inpatient in a hospital or SNF for 60 consecutive days. If a beneficiary is in an SNF, it ends when he/she has not received any skilled nursing care for 60 consecutive days. There is no limit to the number of benefit periods a beneficiary may have. The beneficiary must pay the Part A deductible for each benefit period. This is also known as a spell of illness. For a hospice, a benefit period is two 90-day periods plus a 30-day period, or an indefinite extension if necessary.

Bilateral Multiple Surgery Multiple surgeries performed on two alike parts of the body, such as the left and right hand.

Bilateral Surgery Procedures that are performed on both sides of the body during the same operative session or on the same day.

Bill/Claim `Bill’ and `claim’ are used interchangeably for Part A and institutional Part B services (i.e., those services billed through fiscal intermediaries). `Claim’ is used for Part B physician/supplier billed through carriers. A bill/claim is essentially a request for payment for medical services rendered by a Medicare provider. Claims are generally submitted on standard claim forms (UB-92 or HCFA 1500) or in an approved electronic format (National Standard Format, ANSI X.12, etc.)

Biologicals Drugs produced by extraction from plant or animal tissue, rather than chemical synthesis. Examples: gamma globulin (from horse serum); human growth hormone.

Blood Deductible Deductible equal in cost to the first three pints of whole blood (or packed red blood cells) received by a beneficiary in a calendar year.

Blue Cross and Blue Shield Association (BCBSA) A national non-profit corporation which promotes the betterment of public health and security, and obtains wide public acceptance of the principle of voluntary, non-profit prepayment of health services. BCBSA holds all rights to the words and symbols that represent both corporations.

Board Certified Physicians who have successfully taken the examination of a medical specialty board.

Buy-in The process whereby a state Medicaid program pays the monthly premiums for Medicare Part B coverage (SMI) in order to provide its Medicaid recipients who are eligible for Medicare with that coverage. Claims processed for the recipients are called crossover claims.