Glossary

An Accountable Care Organization (ACO) is a group of doctors, hospitals, and other providers that share accountability for the cost and quality of care for a defined patient population.

Accounts receivable (A/R) is the money owed to a provider for care already delivered but not yet collected — from payers and from patients.

A/R aging is a report that buckets outstanding accounts receivable by how long each balance has been unpaid, used to spot at-risk revenue and prioritize collections.

An add-on code is a CPT code that supplements a primary procedure and can never be billed or paid on its own.

Adjudication is the payer’s process of reviewing a submitted claim against the member’s plan and deciding what to pay — approving, adjusting, or denying it.

An Advance Beneficiary Notice of Noncoverage (ABN) is a standardized CMS notice a provider or supplier gives a Medicare fee-for-service beneficiary before furnishing an item or service that Medicare is expected to deny, so the beneficiary can decide whether to accept financial responsibility.

The allowed amount is the maximum a plan will recognize for a service — the number every other number on the remittance is derived from.

An Ambulatory Payment Classification (APC) groups outpatient hospital services into payment categories for Medicare's Outpatient Prospective Payment System.

ASC payment is the Medicare prospective payment system that pays ambulatory surgical centers a set amount per covered procedure, tied to the same groups used for hospital outpatient services.

Ancillary services are the diagnostic and supportive services that accompany a primary treatment — laboratory, imaging, anesthesia, pathology, and the like — typically ordered or furnished by providers a patient does not personally choose. The No Surprises Act gives the term a precise meaning: at an in-network facility, ancillary services furnished by an out-of-network provider can never be balance billed, even with a signed notice and consent, because they are exactly the services a patient cannot shop for.

A safe harbor is a category of payment or business arrangement that federal regulation (42 CFR § 1001.952) protects from prosecution under the Anti-Kickback Statute, as long as the arrangement meets every condition the safe harbor specifies. Safe harbors are voluntary, and an arrangement that does not fit one is not automatically illegal — it loses the automatic protection and is judged on its own facts.

An appeal is a formal request asking a payer to reverse a denial, arguing with evidence that the original decision was wrong under the plan's own rules.

In Medicare, assignment is an agreement by which a provider or supplier accepts the Medicare-approved amount as full payment for a covered service, billing Medicare directly and limiting what the patient owes to applicable deductible and coinsurance.

An authorization number is the reference a payer issues when it approves a prior authorization — the identifier that ties the approval to the claim for the service it covers.

Billing a patient for the difference between the provider's charged amount and the plan's allowed amount, generally limited to out-of-network care.

A behavioral health carve-out is an arrangement in which mental health and substance use treatment benefits are separated from a health plan's general medical benefits and managed by a specialized organization rather than the main medical plan.

Beneficiary inducement is the offering or transfer of remuneration to a Medicare or Medicaid beneficiary that the offeror knows or should know is likely to influence the beneficiary's choice of a particular provider, practitioner, or supplier. It is prohibited by the beneficiary-inducement civil monetary penalty at 42 U.S.C. § 1320a-7a(a)(5), and “remuneration” is defined to include waivers of coinsurance and deductible amounts. Unlike the Anti-Kickback Statute, which targets remuneration to a referral source, this prohibition targets remuneration offered to the patient.

Benefit verification establishes what a plan actually pays for a specific planned service — and what the patient will owe — where eligibility verification only confirms that coverage is active.

The provider or supplier identified as submitting the claim and requesting payment under the applicable billing arrangement.

Under HIPAA, a breach is an acquisition, access, use, or disclosure of unsecured protected health information in a way the Privacy Rule does not permit, which compromises its security or privacy. An impermissible use or disclosure is presumed to be a breach unless a risk assessment shows a low probability that the information was compromised.

A bundled payment is a single payment for all services related to an episode of care, replacing separate per-service payments for each provider involved.

A person or company that creates, receives, maintains, or transmits protected health information to perform a function for a covered entity — such as billing, claims processing, or collections — and is directly bound by parts of the HIPAA rules.

Capitation is a set payment per patient per period — usually per member per month — made to a provider to cover a specified set of services, without regard to how many services are actually furnished. It pays for a population being covered rather than for anything that happened.

CAQH runs the shared credentialing data source many commercial payers pull from — one profile a provider maintains, rather than one application per payer.

A CARC is the standardized code on a remittance that states why a payer adjusted a claim line — the payer's stated reason for paying less than billed.

Charge capture is the process of recording every billable service a provider delivered so it can be coded and billed — making sure the practice bills for all the care it gave.

Charity care is financial assistance a provider gives to patients who cannot pay for care, based on documented financial need and the provider's policy.

CHIP (the Children's Health Insurance Program) is a jointly federal- and state-funded, state-administered public program that helps cover health care for eligible children, and sometimes pregnant women, in families earning too much for Medicaid but who lack affordable coverage.

A civil monetary penalty is a financial penalty the government can impose through an administrative process — without a criminal conviction or a court trial — for defined health care violations. In the federal health care programs, the HHS Office of Inspector General is the agency that imposes CMPs, under the Civil Monetary Penalties Law.

A controlled group of claim transactions prepared and tracked together for release, transmission, response matching, and reconciliation.

The service-level portion of a claim carrying details such as date, procedure, modifiers, units, charge, diagnosis linkage, and rendering information.

A rejection is a claim returned before adjudication because it failed a format or data edit — it never entered the payer's system and cannot be appealed.

Scrubbing is the automated check a claim passes through before submission — catching the errors that would otherwise come back as a rejection or a denial.

The claim status transaction — X12 276 inquiry and 277 response — lets a provider ask a payer where a submitted claim stands without waiting for the remittance.

The HIPAA transaction for supporting documentation on a claim. It runs in both directions — a provider sending attachment information in support of a claim, and a plan requesting that information from a provider — and each direction is a transaction in its own right.

A clean claim carries everything a payer needs to adjudicate it on first submission — no missing data, no manual intervention, no request for more information.

The clean-claim rate is the percentage of claims paid on first submission without rework, a front-end measure of submission quality.

A clearinghouse is an intermediary that receives claims from providers, scrubs them against payer edits, and routes them electronically to the right payers — returning rejections and remittances.

CMS — the Centers for Medicare & Medicaid Services — is the federal agency that administers Medicare, Medicaid, and related health-insurance programs and sets many of the billing rules the US system follows.

The CMS-1500 is the standard paper claim form for professional services — the layout behind what most practices submit electronically as an 837P.

A federal law allowing workers to continue employer-sponsored health coverage temporarily after leaving a job or reducing hours.

The percentage of the allowed amount a patient pays for a covered service after the deductible has been met.

The Collaborative Care Model (CoCM) is a team-based, measurement-guided approach to treating behavioral health conditions inside a primary care or other medical practice, and Medicare recognizes it through a defined set of monthly care-management billing codes.

A compliance program is the formal system of written standards, oversight, training, communication, auditing, enforcement, and correction an organization uses to prevent, detect, and address violations of the law and of payer and program requirements. In health care, the HHS Office of Inspector General describes an effective compliance program in terms of seven elements and offers it as voluntary guidance rather than a mandate.

A contractual adjustment is the difference between a provider’s billed charge and the amount the payer’s contract allows — an agreed write-down, not a patient balance.

A control point is a defined place in a workflow where information, authorization, transfer, reconciliation, or completion is checked and evidenced.

COB is the set of rules deciding which plan pays first when a patient has more than one — and a denial reason when the order is billed wrongly.

A fixed dollar amount a patient pays for a covered health care service, usually at the time of the visit.

The Correct Coding Modifier Indicator is a flag carried on every National Correct Coding Initiative procedure-to-procedure edit pair, saying whether a modifier may be used to report the two codes together at all. It is the lookup that comes before choosing which modifier to use.

A corrected claim replaces a claim the payer already processed — it fixes an error rather than arguing the decision, and it must be marked as a replacement.

A corrective action plan is the documented remediation a practice adopts after a compliance problem is found — through an internal audit, ongoing monitoring, a staff report, or an outside finding. A useful plan names the problem and its root cause, the specific fix, who owns it and by when, and how the practice will confirm the fix worked, often through a follow-up re-audit. It is the step that turns a finding into a change.

Cost sharing is the portion of a covered service a patient pays — deductible, copayment, and coinsurance — calculated from the plan's allowed amount, not the billed charge.

A health plan, a health care clearinghouse, or a health care provider that transmits health information electronically in connection with a HIPAA standard transaction — the organizations the HIPAA rules bind directly.

A covered service is one a health plan will pay for under its terms, distinct from a service that was furnished but is not a plan benefit.

A CPT (Current Procedural Terminology) code reports the medical, surgical, or diagnostic service a provider performed — the “what was done” on a claim.

Credentialing is the process of verifying a provider’s qualifications so they can join a payer’s network or be granted privileges at a facility.

A crossover claim is a claim automatically forwarded from a primary payer (typically Medicare) to a secondary payer (often Medicaid) so the secondary can adjudicate what remains.

The date of service is the date a service was furnished, as reported on the claim. It anchors the filing clock, fixes which coverage rules and fee-schedule amounts apply, and for some services decides which entity is permitted to bill — and there is no single federal definition of it, only service-specific rules.

Days in A/R is the average number of days it takes to collect receivables, a core measure of revenue-cycle speed.

A decision right states which role has authority to make a defined operational, coding, compliance, financial, technical, or policy decision.

The amount a patient pays for covered services each plan year before the health plan begins to share the cost.

A denial is a claim a payer has processed and refused to pay, in whole or part, with the reason returned as standardized codes on the remittance.

Denial prevention is the front-end work that stops a claim from being denied in the first place, distinct from working denials after they occur.

The denial rate is the percentage of submitted claims denied by the payer, a measure of how much rework the revenue cycle must absorb.

Designated health services (DHS) are the specific categories of health service the Stark Law restricts a physician from referring for. They are enumerated by statute (42 U.S.C. § 1395nn(h)(6)) and defined by regulation (42 CFR § 411.351), and CMS publishes an annually updated code list identifying the CPT/HCPCS codes that are DHS. The Stark prohibition applies only when the referred service is a DHS payable by Medicare — a referral for a service outside the categories is not restricted by Stark.

Under HIPAA, the designated record set is the group of records a covered entity uses to make decisions about individuals — expressly including the medical records and the billing records a provider maintains, and the enrollment, payment, and claims-adjudication systems a health plan maintains. It is the set of information an individual has a right to inspect and obtain a copy of under the right of access.

A DSH payment is a Medicare add-on to inpatient hospital payment for hospitals that treat a disproportionately large share of low-income patients.

A dual-eligible beneficiary is a person who qualifies for both Medicare and Medicaid at the same time, so both programs help cover their care.

The effective date is the day a provider's participation with a payer begins — and the day their claims start being payable. It is not the approval date.

EFT is the movement of the money itself. It arrives separately from the remittance that explains it, which is why the two have to be matched.

Electronic health information (EHI) is the category of data the federal information blocking rule protects. Under 45 CFR 171.102 it means electronic protected health information — to the extent that information would be included in a designated record set — regardless of whether the records are held by or for a covered entity, and excluding psychotherapy notes and information compiled for litigation. Because a designated record set includes billing records, a billing operation's electronic claim and payment data can be EHI.

The eligibility transaction — the X12 270 inquiry and 271 response — is the electronic exchange that lets a provider verify a patient's coverage and benefits with a payer in real time or batch.

Eligibility verification is confirming, before or at the visit, that a patient’s insurance is active and covers the planned service — and what the patient will owe.

An encounter is a single contact between a patient and a provider for the delivery of care — the visit, service, or stay that a claim reports.

An EOB is the statement a health plan sends the patient explaining how a claim was processed — what was billed, allowed, and paid, and what the patient owes. It is not a bill.

EPSDT is Medicaid's federally required child health benefit that covers comprehensive preventive screening, diagnosis, and any medically necessary treatment for enrolled individuals under age 21.

Ten categories of health care services that ACA-compliant individual and small-group plans must cover.

Evaluation and Management (E/M) codes report office visits, hospital visits, and other encounters where a provider assesses and manages a patient's condition.

An exception queue holds work that cannot continue through the normal path and gives each item a reason, owner, deadline, and next action.

A federal statute governing how debts owed by consumers are collected. It applies principally to parties collecting debts owed to someone else, which is why a practice's own billing staff and a collection agency working the same balance are usually governed by different rules.

A fee schedule is a payer's published list of the amounts it will pay for each covered service code, used to derive the allowed amount on a claim.

Fee-for-service (FFS) is a payment method in which a health plan or program pays a provider a separate amount for each covered service delivered, based on the specific services billed rather than a fixed per-member payment.

A tax-advantaged account, typically offered through an employer, used to pay for qualified medical expenses with funds that are usually use-it-or-lose-it annually.

A health plan's list of covered prescription drugs, organized into tiers with different cost-sharing levels.

A claim indicator communicating whether the transaction is an original, replacement, void, or another defined submission frequency under the applicable instructions.

The post-procedure window during which related follow-up care is bundled into the procedure's payment and cannot be billed separately.

A No Surprises Act-required written estimate of expected charges for uninsured or self-pay patients.

GME payments are Medicare add-ons to hospital payment that help fund the cost of training resident physicians, paid per resident and tied to teaching hospitals.

A group code is the code paired with every adjustment on a remittance that says who bears the amount — the practice, the patient, or the payer.

A guarantor is the individual legally responsible for paying a patient's bill, who may be the patient or another party such as a parent or spouse.

HCPCS Level II is the standardized code set for products, supplies, and services not described by CPT — durable medical equipment, drugs, ambulance transport, and certain professional services.

A tax-advantaged savings account paired with a high-deductible health plan, used to pay for qualified medical expenses.

ICD-10 is the diagnosis coding system used in the US to report a patient’s condition on a claim — the “why” that justifies a service.

ICD-10-PCS is the procedure coding system used to report inpatient hospital procedures, distinct from the ICD-10-CM diagnosis codes used across all settings.

A provider or facility that has a contracted agreement with a patient's health plan to accept a negotiated allowed amount.

Incident-to billing lets a non-physician practitioner's service be billed under a supervising physician's NPI when strict requirements are met, paying at the physician rate.

Incorporation by reference is a contract naming another document — a provider manual, a medical policy, a fee schedule exhibit — and making it part of the agreement. It is why a payer contract can be a few pages long and still bind a practice to hundreds.

A Medicare contractor's decision on a claim for Part A or Part B benefits. It is the decision an appeal appeals — and an action that is not an initial determination carries no appeal rights at all.

The IRF PPS is Medicare's prospective payment system for inpatient rehabilitation facilities, paying a single bundled amount per stay based on a patient classification and case characteristics.

The LEIE is the HHS Office of Inspector General's published list of individuals and entities currently excluded from federal health care programs. A provider checks it to confirm that the people and businesses it employs or contracts with are not excluded, because federal programs pay nothing for items or services an excluded person furnishes.

A Local Coverage Determination (LCD) is a decision issued by a Medicare Administrative Contractor (MAC) about whether a particular item or service is considered reasonable and necessary, and therefore eligible for coverage, within that contractor's geographic jurisdiction.

The Long-Term Care Hospital Prospective Payment System is Medicare's payment methodology for eligible long-term care hospitals.

A machine-readable file is a digital file structured so that a computer can import and process it without a person reading each entry. Federal price-transparency rules use the format as their vehicle for bulk price disclosure: the Transparency in Coverage rule requires health plans and issuers to post files of their negotiated rates and out-of-network allowed amounts, and the Hospital Price Transparency rule requires hospitals to post a file of their standard charges. The files are meant for software and analysis, not for a quick human lookup.

The Medicare Access and CHIP Reauthorization Act is the 2015 law that created the Quality Payment Program, including the MIPS and Advanced APM tracks.

A managed care organization (MCO) is a health plan that contracts with a state Medicaid agency to deliver covered benefits to enrolled members in exchange for a set per-member payment, becoming the payer that providers bill for those members' services.

A Medicaid state plan is the formal agreement a state files with CMS describing how it runs its Medicaid program — eligibility, benefits, payment — within federal rules.

Medical necessity is a payer's coverage standard — whether a service was appropriate for the patient's condition under the plan's published criteria.

A Medicare Administrative Contractor (MAC) is a private organization that CMS contracts with to process and pay Medicare fee-for-service claims within a defined geographic area.

Medicare Advantage (Medicare Part C) is a privately administered alternative to Original Medicare that bundles Part A and Part B and usually Part D, with plan-specific rules a claim must follow.

The Medicare Beneficiary Identifier (MBI) is the unique, randomly generated 11-character alphanumeric code on a person's Medicare card that identifies them in Medicare claims and related transactions, replacing the older Social Security number-based identifier.

Medicare Secondary Payer (MSP) refers to the set of situations and rules under which another insurer or plan is required to pay a patient's medical claim before Medicare does, making Medicare the secondary rather than the primary payer.

A Medicare Summary Notice (MSN) is the statement Medicare sends beneficiaries showing the services billed, what Medicare paid, and what the patient may owe.

Medication-assisted treatment (MAT) is the clinical use of FDA-approved medications, combined with counseling and behavioral therapies, to treat substance use disorders — most commonly opioid and alcohol use disorders.

A Medigap (Medicare Supplement) policy is private insurance that pays some of the cost-sharing a beneficiary owes under Original Medicare, after Medicare pays its share.

Mental health parity is the principle — anchored in federal law — that health plans must treat coverage for mental health and substance use disorder care no more restrictively than they treat coverage for comparable medical and surgical care.

The HIPAA Privacy Rule's requirement to limit the protected health information used, disclosed, or requested to the least needed to accomplish the purpose — with defined exceptions, including disclosures for treatment.

The Merit-based Incentive Payment System (MIPS) is a Medicare program that adjusts clinician payments based on performance in quality, cost, improvement activities, and promoting interoperability.

A modifier is a two-character suffix on a procedure code that changes what the code reports — without changing the code itself.

Modifier 25 identifies a significant, separately identifiable evaluation and management service performed by the same clinician on the same day as a procedure.

Modifier 59 indicates that a procedure or service is distinct and independent from another service performed on the same day and is not normally reported together.

An MS-DRG (Medicare Severity-Diagnosis Related Group) classifies an inpatient hospital stay into a payment group based on diagnoses and procedures, driving a single bundled payment.

The multiple-procedure rule reduces reimbursement for additional procedures performed by the same clinician on the same day or during the same session.

The National Correct Coding Initiative (NCCI) is a CMS program of edits that flag code pairs and services that should not be billed together, to prevent improper payment.

A National Coverage Determination (NCD) is CMS's nationwide rule on whether, and under what conditions, Medicare covers a specific service.

A National Drug Code (NDC) is a unique three-segment identifier for a drug's labeler, product, and package size, used on claims to report the specific product dispensed.

Net collections is the percentage of expected reimbursement actually collected after payer adjustments and write-offs, a core measure of revenue-cycle effectiveness.

Network status is whether a provider participates in a patient's specific plan — in-network or out-of-network — which changes coverage, cost sharing, and balance-billing exposure.

Federal law effective January 1, 2022 that protects patients from surprise balance bills in emergency and certain facility-based settings.

The NPI is the standard 10-digit identifier for a healthcare provider — the number that says who rendered and who is billing for a service.

NPPES — the National Plan and Provider Enumeration System — is the CMS system that assigns and maintains National Provider Identifier (NPI) records.

The annual window during which individuals can enroll in or change health insurance plans.

The design connecting roles, processes, decisions, systems, controls, information, governance, and measures to operational outcomes.

A provider or facility that has no contracted agreement with a patient's health plan, typically resulting in higher patient cost.

The annual cap on a patient's cost-sharing for covered in-network services; once reached, the plan pays 100% of allowed amounts.

An overpayment is money received beyond what was owed. It is not the provider's money, and how it must be handled is set by rules rather than by choice.

A partial hospitalization program (PHP) is a structured, intensive form of outpatient behavioral health treatment in which a person attends several hours of care on most days of the week but returns home each night rather than staying overnight.

Patient responsibility is the share of the allowed amount the plan assigns to the patient — deductible, copay, or coinsurance. It is set by the plan, not the provider.

A patient statement is the bill a practice sends a patient or guarantor for the balance left after the plans that owe anything have paid. It is the practice's own document — unlike an EOB, which comes from the plan and is not a request for payment — and no federal rule prescribes its format, its contents, or how often it is sent.

Contracting negotiates the terms and the rates. Credentialing verifies who you are. They are separate, and being good at one says nothing about the other.

"Payer of last resort" means Medicaid generally pays for a covered service only after all other available insurance and legally liable third parties have paid, making it the final source billed rather than the first.

A payment policy indicator is a per-code flag in a fee schedule that says whether a particular payment rule — bilateral surgery, multiple procedures, assistant at surgery, a professional/technical split, a global period — applies to that code. It is what decides whether appending a payment modifier changes anything.

Payment posting is recording what a payer decided against each claim — the payment, the adjustments, and the reasons. It is data entry that determines what happens next.

Reconciliation proves that what was posted matches what the bank received. It is the control that catches the payments posting never saw.

PECOS is Medicare's provider enrollment system — where a provider's Medicare enrollment record lives, is updated, and is revalidated.

A peer-to-peer review is a conversation between the ordering provider and a payer's physician reviewer to discuss the clinical basis for a service the payer has questioned or denied.

A place-of-service (POS) code reports where a healthcare service was furnished — office, hospital, ambulatory surgical center, telehealth, and so on — and can change how a claim is paid.

A health condition that existed before a patient's health coverage enrollment date.

Precertification is a payer's advance review confirming that a planned service meets its coverage criteria before the service is provided — for most payers, another name for prior authorization.

A predetermination is a payer's advance, usually non-binding review of whether a service would be covered — an estimate of coverage rather than a required approval.

The amount paid, often monthly, to maintain health insurance coverage, regardless of whether services are used.

Prepayment review is a payer's examination of a claim — and often the medical records behind it — before the claim is paid. Because the review happens first, the claim is held and payment depends on the outcome: the payer issues an initial determination once it has what it needs, and if the requested records do not arrive complete and on time, the claim is denied. It is the counterpart of post-payment review, which revisits a claim after it has already been paid.

Primary source verification confirms a credential with the body that issued it — not with the provider, and not with their copy of it.

Prior authorization is a payer’s requirement that a provider obtain approval before delivering certain services — without it, the payer may not cover the care.

Privileging grants a credentialed provider permission to perform specific procedures at a specific facility. It is about scope, not about payment.

The role accountable for an end-to-end process, including its design, controls, performance, exceptions, and improvement.

Individually identifiable health information — including the data on a claim — that a HIPAA covered entity or business associate creates, receives, maintains, or transmits in any form. It is the information the HIPAA Privacy Rule protects.

Enrollment registers a provider with a payer so their claims route and pay. It follows credentialing, and it is the step that actually touches revenue.

A provider exclusion is a federal action — commonly listing on the OIG LEIE — that bars a provider from billing federal healthcare programs; claims from excluded providers are not payable.

A PTAN (Provider Transaction Account Number) is a Medicare-specific identifier some contractors assign to a provider's enrollment, used alongside the NPI in Medicare billing.

A change in circumstances, such as marriage or loss of coverage, that triggers eligibility for a Special Enrollment Period.

The qualifying payment amount (QPA) is the benchmark figure the No Surprises Act turns on. Under 45 CFR 149.140 it is generally a health plan's or issuer's median contracted rate for the same or similar item or service in the geographic region, calculated from a base date and trended forward by the Consumer Price Index. It does two jobs: it is generally the basis for the patient's in-network cost-sharing in a protected surprise-billing situation, and it is one of the factors a certified IDR entity weighs when it resolves an out-of-network payment dispute.

A qui tam lawsuit is a civil action brought under the False Claims Act by a private person — a “relator” — on the government's behalf and in the government's name. The complaint is filed under seal so the government can investigate and decide whether to take over the case; if it declines, the relator may pursue it alone. A successful relator may receive a share of the recovery, and the False Claims Act protects whistleblowers from retaliation.

A RARC is a standardized code that supplements a CARC on the remittance, adding the detail the adjustment reason alone does not carry.

Reassignment is the arrangement under which Medicare pays someone other than the individual who furnished the service — an employer, a group, or a contracted entity. It is prohibited by default and permitted only through defined exceptions, and it carries oversight obligations that survive the outsourcing decision.

A record retention schedule is a written policy that lists each type of record a practice holds and states how long it is kept and when it is destroyed. It turns the several overlapping retention rules that apply to medical and billing records — state law, Medicare and Medicaid requirements, payer contracts, and claim-review windows — into a single instruction staff can follow, setting each record type's period to the longest authority that reaches it and specifying secure disposal at the end.

Recoupment is a payer's recovery of money already paid on a claim, typically by withholding from future payments rather than demanding repayment.

A Recovery Audit Contractor (RAC) is a private contractor CMS uses to review already-paid Medicare fee-for-service claims and identify improper payments — both overpayments to recover and underpayments to correct. Authorized by section 1893(h) of the Social Security Act (42 U.S.C. § 1395ddd(h)), Recovery Auditors work by region, conduct post-payment review, and are paid on a contingency basis from the amounts recovered. The Recovery Auditor identifies the improper payment, but the Medicare Administrative Contractor adjusts the claim, issues the demand, and recovers the money.

Written authorization from a primary care provider for a patient to receive care from a specialist or for specific services.

The professional identified as referring the patient or directing a service when that role is applicable to the claim.

A relative value unit (RVU) measures the relative work, practice expense, and liability of a service, and is the basis for Medicare's physician fee schedule rates.

A remittance advice is the payer’s explanation to the provider of how a claim was paid or denied — what was allowed, paid, adjusted, and left to the patient. The electronic form is the ERA (X12 835).

The individual provider identified as performing or rendering the billed service when required on the claim.

Revalidation is re-proving an enrollment that already exists. Missing it can deactivate a provider who has changed nothing and done nothing wrong.

A reverse false claim is a violation of the civil False Claims Act that consists not of wrongly obtaining money from the government, but of wrongly keeping money owed to it. Under 31 U.S.C. § 3729(a)(1)(G), a person is liable who “knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay or transmit money” to the government. The Act defines an “obligation” to include “the retention of any overpayment,” which is what links the reverse false claim to the 60-day overpayment rule: an identified Medicare or Medicaid overpayment kept past the deadline to return it becomes an obligation whose avoidance is a reverse false claim.

A secondary claim bills the next plan after the primary has paid — and it must carry what the primary did, or it cannot be adjudicated.

Self-pay describes a patient who is responsible for their own bill — because they are uninsured, out of network, or for a service their plan does not cover.

A measurable commitment for a defined service, population, clock, completion state, evidence, owner, and breach response.

A window outside Open Enrollment during which individuals can enroll in or change plans due to a qualifying life event.

Step therapy is a payer requirement that a patient try a preferred, usually lower-cost treatment first, and have it prove inadequate, before a more expensive alternative is covered.

The subscriber holds the insurance policy; a dependent is someone else covered under it. Billing the patient's information where the subscriber's belongs is a common, avoidable denial.

A superbill is a pre-coded encounter form a provider uses to record the services furnished during a visit, used to generate a claim.

Unexpected balance bills from out-of-network providers involved in a patient's emergency care or services delivered at an in-network facility.

Telehealth is the delivery of clinical services over telecommunications between a patient and a provider at different locations, billed under rules that vary by payer and by date.

Third-party liability (TPL) means another payer — commercial insurance, Medicare, auto, or workers' compensation — is responsible for a claim before Medicaid pays, because Medicaid is payer of last resort.

Timely filing is the deadline by which a payer must receive a claim. Miss it and the claim is denied on the date alone, whatever its merits.

The UB-04 is the standard claim form for institutional services — hospitals and facilities — and the counterpart to the professional CMS-1500.

A traditional method for pricing out-of-network charges based on typical rates for a service in a geographic area.

An underpayment is a claim paid at less than the contract requires. Unlike a denial, it arrives as a payment — so nothing about it looks wrong.

Utilization management is the set of review processes a health plan uses to decide whether it will cover a service — prior authorization is the best known of them, but it is one member of a family that also includes concurrent and retrospective review, step therapy, and referral requirements.

Value-based care is a payment and delivery approach that rewards providers for the value (quality relative to cost) of care rather than the volume of services furnished.

A write-off removes a balance from accounts receivable. Whether it was a decision or a default is what separates a healthy one from a loss.

42 CFR Part 2 is a federal regulation that gives special confidentiality protection to the records of patients treated for substance use disorders by federally assisted treatment programs, generally requiring patient consent before those records are disclosed.

The 837 is the standard electronic transaction that carries a claim to a payer — the HIPAA-mandated format behind nearly every claim submitted today.