Glossary¶
Plain-words definitions for the terms the tables use. Each table links the term the first time it appears.
- Allowed amount
- The total the insurer agreed the provider may be paid for a service: the insurer's share plus the patient's share. Usually lower than the billed charge.
- APC (ambulatory payment classification)
- Medicare's grouping for hospital outpatient services; each APC has a national payment amount, adjusted by locality.
- Attestation
- Since 2026, a signed statement by a senior hospital officer that the price file is complete and accurate.
- Billed charge (gross charge)
- The hospital's list price, before any insurer discount. Almost nobody pays it; it is the starting point for negotiation.
- Cash price (discounted cash price)
- What the hospital charges a patient who pays directly, without insurance. Sometimes lower than the negotiated insured price.
- CPT / HCPCS
- Code sets for procedures and services. CPT codes are five digits; HCPCS adds letters for supplies and some services.
- DRG (diagnosis-related group)
- Medicare's grouping for inpatient stays; the hospital is paid one amount per stay by group.
- Explanation of benefits (EOB)
- The statement an insurer sends after a claim: what was billed, what was allowed, what the plan paid, what the patient owes. Not a bill.
- Facility fee
- A charge for the use of the building and staff, separate from the clinician's fee. Hospital-owned outpatient offices can bill one; independent offices generally do not.
- In network
- A provider that has a contract with the insurer at a negotiated rate.
- Machine-readable file (MRF)
- The file a hospital or insurer must post under the transparency rules, in a format a program can read.
- Medicare rate
- What Medicare pays for the same service. Used here as the benchmark because it is public and follows one published method: a national rate adjusted for the local wage index and the setting, so two facilities in the same area are compared on the same footing.
- Negotiated rate
- The price a specific insurer and a specific provider agreed to for a specific service.
- NPI (National Provider Identifier)
- A ten-digit number for every provider and facility; Type 1 for individuals, Type 2 for organizations.
- Percent of Medicare
- A price divided by Medicare's rate for the same service. 200% means twice what Medicare pays.
- Shoppable service
- A service a patient can schedule in advance. 45 CFR 180.60 names 70 that every hospital must display, and the hospital picks the rest of its 300.
Open¶
- Add terms as the tables need them.