Reference · glossary

Medical billing glossary

The words billers use at the desk, defined in one sentence and then explained with an example.

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Written so a practice owner can read a weekly report, a remittance or a payer letter without a translator.

150 terms, each defined in one sentence, with an example and a review date.

Last reviewed November 5, 2026 by the Remitwright billing team. Editorial policy

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2

3 terms

270/271 eligibility transaction: A 270/271 eligibility transaction is the HIPAA-standard X12 pair for checking coverage electronically: the provider or its clearinghouse sends a 270 inquiry about a patient's eligibility and benefits, and the payer returns a 271 response.
276/277 claim status transaction: A 276/277 claim status transaction is the HIPAA-standard X12 pair for asking a payer where a submitted claim stands: the provider or clearinghouse sends a 276 request, and the payer returns a 277 response with a status category code and a status code.
277CA claim acknowledgment: A 277CA is the X12 claim acknowledgment a payer's front end returns after receiving an 837 file, reporting claim by claim whether each claim passed the front-end edits and was accepted for processing, or was rejected and has to be corrected and sent again.

8

2 terms

837I: The 837I is the X12 electronic transaction used to submit institutional claims, the facility-based services of hospitals, skilled nursing facilities, home health agencies, hospices and similar providers, to payers; it is the electronic counterpart of the paper UB-04 form.
837P: The 837P is the X12 electronic transaction used to submit professional claims, the services of physicians, non-physician practitioners, therapists, ambulance and other non-institutional providers, to payers; it is the electronic counterpart of the paper CMS-1500 form.

9

1 term

999 acknowledgment: A 999 acknowledgment is the X12 implementation acknowledgment a receiver sends back after an EDI file arrives, reporting whether each transaction set in the file passed the syntax and implementation guide checks and was accepted, accepted with errors noted, or rejected.

A

6 terms

A/R aging buckets: A/R aging buckets are the columns of an aging report that group every open balance by how many days it has been outstanding, counted from the charge date or the claim submission date, so that current claims and overdue ones can be worked and reported separately.
Accounts receivable (A/R): Accounts receivable (A/R) is the total of all charges a practice has billed to insurance payers and patients that have not yet been paid, adjusted or written off, tracked claim by claim and usually sorted by how long each balance has been open.
Additional documentation request (ADR): An additional documentation request (ADR) is a written request from a Medicare review contractor, such as a MAC or a Recovery Audit Contractor, for the medical records and other documents it needs to decide a claim selected for prepayment or post-payment review.
Advance beneficiary notice (ABN): An Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is the notice a Medicare fee-for-service provider or supplier gives a beneficiary before furnishing a service Medicare is expected to deny, so that financial liability can transfer to the patient.
Allowed amount: The allowed amount is the maximum a health plan will recognize for a covered service, also called the eligible expense, payment allowance, negotiated rate or contracted rate. The payer's payment plus the patient's share add up to it; the rest of the charge is adjusted off.
Authorization units: Authorization units are the measured amount of a service a payer has approved for a specific patient, code and date range, counted in the payer's unit of measure such as visits, hours or timed increments, beyond which claims deny for exceeding the authorization.

B

2 terms

Bad debt: Bad debt is an amount a patient owes, such as a deductible, coinsurance or self-pay balance, that the provider has billed and tried to collect and then writes off as uncollectible, as distinct from a discount, a charity adjustment or a contractual write-off.
Balance billing: Balance billing is billing a patient for the difference between the provider's full charge and the amount the payer allowed, on top of the deductible, copay or coinsurance the patient already owes under the plan.

C

28 terms

Capitation: Capitation is a payment method in which a health plan or provider receives a set amount for each enrolled member for a period, usually per member per month, to cover a defined set of services whether the member uses many of them or none.
CAQH: CAQH is the organization, renamed DataSpring, powered by CAQH in June 2026, behind the CAQH Provider Data Portal (formerly ProView), where a clinician enters credentialing data once and authorizes participating payers to pull it instead of completing a separate application for each.
Charge capture: Charge capture is the process of recording every billable service, supply and unit a provider delivers so that it reaches a claim. Charge lag is the time between the date of service and the date the charge is entered.
Charge entry: Charge entry is the step in the billing cycle where each service from the encounter is entered into the practice management system as a claim line: the CPT or HCPCS code, modifiers, units, diagnosis pointers, date and place of service, rendering provider and fee.
Claim adjustment reason code (CARC): A claim adjustment reason code (CARC) is a standardized code, published by X12 and reported on an electronic remittance advice or paper remittance alongside a group code, that explains why a payer paid a claim or service line differently from the amount billed, including every denial and reduction.
Claim appeal: A claim appeal is a formal, written request that a payer reverse its decision to deny or reduce payment on a claim, supported by records and the policy or contract language that shows the claim should be paid.
Claim denial: A claim denial is a payer's decision, after it has processed a claim, not to pay all or part of it. The remittance carries a claim adjustment reason code (CARC) and usually a remark code (RARC) explaining why.
Claim frequency code: A claim frequency code is the one-character code that tells a payer where a bill sits in a claim's history: an original bill, one of a series of interim bills, a replacement of a claim already processed, or a void that cancels one.
Claim rejection: A claim rejection is a claim sent back by a clearinghouse or payer before it is adjudicated, because it failed a format, syntax or required-field edit. The payer has not processed it, so it is not a denial and does not count as received.
Claim scrubbing: Claim scrubbing is the automated review of a claim before it is submitted, in which software checks the data against formatting rules, code validity, payer-specific requirements and coding edits such as NCCI, and flags anything a payer would reject or deny so it can be fixed first.
Clean claim: A clean claim is a claim that contains all the information a payer needs to adjudicate it, with no errors, omissions or missing attachments, so that it can be processed and paid without being returned, pended or denied for a correctable reason.
Clearinghouse: A clearinghouse is a HIPAA-covered intermediary that receives claims from a provider's billing system, checks them against format and payer edits, converts them to the X12 837 standard each payer accepts, routes them, and returns acknowledgments, claim status and electronic remittances.
CMS-1500: The CMS-1500 is the standard paper claim form used by physicians, other practitioners and suppliers to bill payers for professional services; the 837P is its electronic equivalent, and the form was once known as the HCFA 1500.
CMS-1500 box 24J: CMS-1500 box 24J is the rendering provider ID field on each service line of the paper professional claim: the NPI of the person or company that performed or supervised the service goes in the unshaded lower half, and a non-NPI identifier, when a payer needs one, goes in the shaded upper half.
CMS-855B: The CMS-855B is the Medicare enrollment application that clinics, group practices and other Part B suppliers, such as independent laboratories and ambulance suppliers, use to enroll, revalidate, report changes and accept reassignments, on paper or through PECOS.
CMS-855I: The CMS-855I is the Medicare enrollment application that individual physicians and non-physician practitioners use to enroll, revalidate, reactivate, update their enrollment data, and add, change or end a reassignment of benefits, on paper or through PECOS.
Coinsurance: Coinsurance is the percentage of the cost of a covered service that the patient pays after meeting the deductible, with the plan paying the rest of the allowed amount. On a remittance it appears as patient responsibility with CARC 2.
Condition code: A condition code is a two-character code from the National Uniform Billing Committee that reports a circumstance or event affecting how an institutional claim is processed, entered in form locators 18-28 of the UB-04 or the matching part of the 837I.
Consolidated billing: Consolidated billing is the Medicare rule that makes one provider responsible for billing nearly all of a patient's services, including those outside suppliers furnish: the skilled nursing facility during a covered Part A stay, or the primary home health agency while a home health plan of care is open.
Consumer-directed care: Consumer-directed care, which Medicaid calls self-directed services, is an arrangement in which the member or a representative decides who provides certain home and community-based services and manages them directly, with a financial management service handling payroll and the employer paperwork.
Contractual adjustment: A contractual adjustment is the difference between the amount a provider charges and the amount a payer allows under its contract or fee schedule. It is written off because the provider agreed not to collect it, and it is not a denial, a discount or bad debt.
Conversion factor: A conversion factor is the dollar amount the Medicare Physician Fee Schedule multiplies by a service's geographically adjusted relative value units to turn them into a payment amount. CMS sets it for each calendar year in the fee schedule final rule.
Coordination of benefits (COB): Coordination of benefits (COB) is the process payers use to decide the order in which two or more plans pay for the same patient's care, so the primary plan pays first and each later plan pays only on what remains.
Copay: A copay, or copayment, is a fixed dollar amount a patient pays for a covered health care service, set by the plan for that type of service. Whether it applies before or after the deductible depends on the plan, and on a remittance it appears under patient responsibility with CARC 3.
Corrected claim: A corrected claim is a resubmission that replaces a claim the payer has already received and processed. It carries the payer's original claim number and the claim frequency code for a replacement, so the payer adjudicates the new version in place of the old one.
CPT code: A CPT code is a five-digit code from Current Procedural Terminology, the code set the American Medical Association owns and maintains, that identifies the procedure or service on a claim line. CPT forms Level I of HCPCS.
Credentialing: Credentialing is the process by which a payer or facility verifies a provider's education, licensure, training, work history and malpractice record before approving them to see its members or join its medical staff.
Crossover claim: A crossover claim is a Medicare claim that the Medicare contractor forwards automatically to the patient's secondary payer, such as Medicaid or a Medigap plan, after Medicare adjudicates it, so the provider does not have to file the secondary claim separately.

D

4 terms

Days in A/R: Days in A/R is the average number of days it takes a practice to collect payment after a charge is billed, calculated by dividing debit accounts receivable, with any netted credit balances added back, by the practice's average daily charges over a recent period.
Deductible: A deductible is the amount a patient must pay for covered health care services before the insurance plan starts to pay. It resets each plan year, and on a remittance the amount applied to it appears under patient responsibility with CARC 1.
Denial rate: Denial rate is the percentage of claims that a payer denies on initial adjudication, calculated by dividing the number of claims denied by the number of claims submitted for the same period, and often also calculated on dollars denied against dollars billed.
Downcoding: Downcoding is reporting or paying a service under a lower or less complete code than the one that describes what was performed. It covers a provider undercoding its own claim and a payer or reviewer changing a billed code to a lower one.

E

7 terms

Electronic data interchange (EDI): Electronic data interchange (EDI) is the automated exchange of billing data, such as claims, remittances, eligibility checks and claim status, between a provider or its clearinghouse and a payer, in nationally standard formats instead of paper or manual entry.
Electronic remittance advice (ERA): An electronic remittance advice (ERA) is the standard electronic file, the X12 835 transaction, that a payer sends after adjudicating claims to report, line by line, what was allowed, paid, adjusted and denied and why, using claim adjustment reason codes and remark codes.
Electronic visit verification (EVV): Electronic visit verification (EVV) is the electronic capture of a home visit's facts, who provided the service, who received it, the type of service, the date, the location and the start and end times, so the state Medicaid program can confirm the visit before paying the claim.
Eligibility verification: Eligibility verification is the check, done before or at the time of service, that a patient's insurance is active for the date of service and covers the planned care, including the plan type, the payer to bill, copay and deductible status, and any referral or authorization requirement.
EVV aggregator: An EVV aggregator is a state Medicaid program's central store of electronic visit verification data. It collects verified visits from the state's own EVV system and from any approved third-party systems, so the state can check visits against claims in one place.
EVV exception: An EVV exception is a visit the EVV system could not fully verify, because a clock-in or clock-out is missing, the location or time falls outside the allowed range, or the caregiver, client or service does not match, and that needs a reason code and a note before it can support a claim.
Explanation of benefits (EOB): An explanation of benefits (EOB) is the document a health plan sends to the patient, and in paper form to the provider, after processing a claim, showing what was billed, what the plan allowed, what it paid, what was adjusted and what the patient owes in deductible, coinsurance or copay.

F

4 terms

Face-to-face encounter: A face-to-face encounter is the in-person or telehealth visit, with a physician or another practitioner the regulation allows, that Medicare requires behind every home health certification. It has to relate to the main reason for home health and fall within 90 days before or 30 days after the start of care.
Fee schedule: A fee schedule is a payer's list of the maximum amount it will pay for each procedure, service or supply code, set by contract or by law, which becomes the allowed amount on a claim whenever the provider's charge is higher.
Fee-for-service: Fee-for-service is a payment method in which a payer pays the provider separately for each service performed and billed, such as a visit, a test or a procedure, usually at the amount its fee schedule allows for that code.
First-pass resolution rate: First-pass resolution rate is the percentage of claims that are paid by the payer on the first submission, without a rejection, denial, correction or appeal, calculated by dividing claims paid on first submission by total claims submitted in the same period.

G

2 terms

Global surgical period: A global surgical period is the span around a procedure during which Medicare's single payment for the surgery also covers the related visits and routine care: no postoperative days, 10 days or 90 days depending on the code, plus the day before surgery for major procedures.
Good faith estimate (GFE): A good faith estimate (GFE) is a written, itemized estimate of the expected charges for scheduled or requested care that a provider or facility must give, under the No Surprises Act, to a patient who is uninsured or is not using insurance for that care.

H

7 terms

HCC coding: HCC coding is the assignment of ICD-10-CM diagnosis codes, supported by the medical record, that map to hierarchical condition categories (HCCs), the disease groups the CMS-HCC model uses to calculate a Medicare Advantage member's risk score.
HCPCS: The Healthcare Common Procedure Coding System (HCPCS) is the two-level procedure code set used on Medicare and other health insurance claims: Level I is the American Medical Association's CPT, and Level II is a CMS-maintained set of one letter and four digits for items and services CPT does not describe.
HIPPS code: A HIPPS code, short for Health Insurance Prospective Payment System code, is a five-character alphanumeric code on an institutional claim naming the case-mix group, set from a standard patient assessment, behind a prospective payment to a skilled nursing facility, home health agency or inpatient rehab facility.
HME: HME, home medical equipment, is the equipment and supplies a patient uses at home, such as oxygen, hospital beds, wheelchairs and sleep therapy devices; payers have no separate HME benefit, the items are covered and billed as durable medical equipment, so an HME claim is a DME claim.
Home and community-based services (HCBS): Home and community-based services (HCBS) is Medicaid's name for long-term services and supports delivered in a person's own home or community instead of an institution, such as personal care, homemaker, respite, adult day health and habilitation, offered under waivers and state plan options each state designs.
Home health plan of care: A home health plan of care is the individualized, written set of orders a physician or allowed practitioner establishes for a patient, covering the diagnoses, the services and disciplines, the frequency and duration of visits, medications, goals and the other required items, and every covered visit has to follow it.
Homebound status: Homebound status is Medicare's requirement that a home health patient be confined to the home: leaving home takes a device, special transport or another person's help, or is medically inadvisable, and the patient normally cannot leave home without a considerable and taxing effort.

I

4 terms

ICD-10-CM: ICD-10-CM, the International Classification of Diseases, Tenth Revision, Clinical Modification, is the US code set for diagnoses and other reasons for care, and the code set HIPAA-covered claims use to say why each service was needed.
IDD services: IDD services are Medicaid services for people with intellectual and developmental disabilities, given in an intermediate care facility (ICF/IID) or in the community through home and community-based services waivers that cover habilitation, day and employment supports, respite and case management.
Incident-to billing: Incident-to billing is the Medicare rule that lets a physician or other qualifying practitioner bill, under their own NPI, for services that auxiliary staff or a nonphysician practitioner furnish as an integral part of the practitioner's own care, in an office or clinic and under direct supervision.
Independent dispute resolution (IDR): Independent dispute resolution (IDR) is the federal process under the No Surprises Act in which a certified IDR entity decides the payment for a protected out-of-network claim by choosing either the provider's offer or the plan's offer after negotiation fails.

L

4 terms

Loaded mileage: Loaded mileage is the distance a transportation provider drives while the Medicaid member is in the vehicle, from pickup to drop-off. It is the mileage fee-for-service NEMT programs pay, as opposed to the empty miles a driver covers with no member on board.
Local coverage determination (LCD): A local coverage determination (LCD) is a decision by a Medicare Administrative Contractor (MAC) on whether a particular item or service is covered across its jurisdiction under Medicare's reasonable and necessary standard, written where no national coverage determination applies or to define one further.
Locum tenens: Locum tenens is the arrangement in which a substitute physician or physical therapist covers for an absent regular clinician and is paid per diem or on a similar fee-for-time basis, which Medicare now calls a fee-for-time compensation arrangement.
Low utilization payment adjustment (LUPA): A low utilization payment adjustment (LUPA) is the Medicare home health rule that pays a 30-day period per visit, at national per-visit rates by discipline, instead of the full period payment, when the agency furnishes fewer visits than the threshold set for that period's case-mix group.

M

23 terms

Managed care organization (MCO): In Medicaid, a managed care organization (MCO) is a health plan that contracts with the state Medicaid agency to cover enrolled members for a set payment per member per month, called capitation, and carries the financial risk for a broad package of services, such as inpatient hospital and physician care.
Managed long-term services and supports (MLTSS): Managed long-term services and supports (MLTSS) is the delivery of Medicaid long-term services and supports through capitated managed care plans, so a home care agency or other provider is contracted, authorized and paid by the member's plan rather than billing the state directly.
Medicaid fiscal agent: A Medicaid fiscal agent is a contractor that processes or pays provider claims on behalf of a state Medicaid agency, and it may also operate the state's Medicaid Management Information System (MMIS), the claims system behind fee-for-service Medicaid.
Medicaid waiver: A Medicaid waiver is federal approval for a state to set aside certain Medicaid rules, such as statewideness, comparability or freedom of choice, so it can run a program its regular state plan would not allow, most often home and community care for people who qualify for an institutional level of care.
Medical necessity: Medical necessity is the standard payers use to decide whether a service or supply was needed to diagnose or treat an illness, injury, condition or its symptoms and met accepted standards of medicine. A claim that fails it is denied as not medically necessary, usually with CARC 50.
Medically unlikely edits (MUE): A medically unlikely edit (MUE) is the maximum number of units of service for a HCPCS or CPT code that the same provider would report for the same patient on the same date of service on the vast majority of correctly coded claims. Lines above the value are denied or reduced.
Medicare Administrative Contractor (MAC): A Medicare Administrative Contractor (MAC) is a private insurer that CMS contracts to process Original Medicare Part A and Part B claims, or durable medical equipment claims, for a defined geographic jurisdiction.
Medicare opt-out: Medicare opt-out is the status of an eligible physician or practitioner who has filed an opt-out affidavit with each MAC and treats Medicare beneficiaries only under private contracts, with no Medicare payment for those services, in two-year periods.
Medicare reconsideration: A Medicare reconsideration is the second level of appeal for Original Medicare Part A and Part B claims: an independent review of the administrative record, including the initial determination and the redetermination, by a Qualified Independent Contractor (QIC).
Medicare redetermination: A Medicare redetermination is the first level of appeal for Original Medicare Part A and Part B claims: a review of the initial claim determination by Medicare Administrative Contractor staff who were not involved in making it.
Modifier 24: Modifier 24 is added to an evaluation and management (E/M) code to show that a visit by the same physician during the postoperative period of a procedure was unrelated to that procedure, so it is paid outside the global surgical package.
Modifier 25: Modifier 25 is added to an evaluation and management (E/M) code to tell the payer that the visit involved distinct evaluation work, beyond what the procedure performed by the same provider on the same day already includes.
Modifier 26: Modifier 26 is added to a procedure code that has separate professional and technical components to bill only the professional component: the physician's interpretation and written report, without the equipment, staff and supplies that make up the technical side.
Modifier 57: Modifier 57 is added to an evaluation and management (E/M) code for the visit, on the day before or the day of a major surgery, that led to the initial decision to operate, so that visit is paid outside the global surgical package.
Modifier 59: Modifier 59 is appended to a procedure code to tell the payer that the service was separate from another procedure billed the same day, performed at a different site or in a different session, so an NCCI bundling edit should not apply. It is used only when no more specific modifier fits.
Modifier 95: Modifier 95 is appended to a procedure code to tell the payer that the service was delivered over a live two-way video connection rather than in person. Which payers require it, and with which place of service code, is set by each payer.
Modifier GA: Modifier GA tells Medicare that the provider gave the patient a required advance beneficiary notice (ABN) for the item or service on that line and keeps it on file, so that if Medicare denies the line as not reasonable and necessary, the patient rather than the provider is liable.
Modifier GP: Modifier GP identifies a line as physical therapy furnished under a physical therapy plan of care. Medicare requires GP, or its occupational therapy and speech-language pathology counterparts GO and GN, on the codes on its therapy list, whoever bills them.
Modifier GT: Modifier GT is a HCPCS modifier that tells the payer a service reached the patient over a live, two-way audio and video connection. Medicare stopped requiring it on professional claims in 2018, but it still applies to some institutional telehealth claims.
Modifier GY: Modifier GY tells Medicare that the item or service on the line is excluded from coverage by statute or falls outside every Medicare benefit category, so the line is expected to deny, with the patient rather than the provider financially responsible.
Modifier KX: Modifier KX is appended to a procedure code to confirm that the conditions in the payer's coverage policy for that service are satisfied and that the medical record documents it. Medicare uses it for outpatient therapy once a patient's spending passes the annual KX modifier threshold.
Modifier TC: Modifier TC is added to a procedure code that has separate professional and technical components to bill only the technical component, the cost of performing the test with its equipment, technologist time and supplies, when someone else bills the interpretation.
Modifier XU: Modifier XU is one of the four X modifiers CMS created as subsets of modifier 59. It tells the payer a procedure was distinct from another billed the same day because none of its work duplicates what the main procedure normally includes, so an NCCI bundling edit should not apply.

N

8 terms

National Provider Identifier (NPI): The National Provider Identifier (NPI) is the 10-position, intelligence-free number that identifies a health care provider on HIPAA standard transactions such as claims and remittances. Individuals hold Type 1 NPIs; organizations hold Type 2 NPIs.
NCCI edits: NCCI edits are the National Correct Coding Initiative rules CMS publishes to prevent improper payment on Medicare Part B claims: procedure-to-procedure (PTP) edits for code pairs that should not be reported together, and medically unlikely edits (MUEs) for units of service.
NEMT escort: An NEMT escort is a person who travels with a Medicaid member on a non-emergency medical transportation trip because the member needs help to get to and through the appointment, such as a parent with a child or an attendant for a member who cannot travel alone.
NEMT level of service: NEMT level of service is the mode of non-emergency medical transportation a Medicaid member is approved for, based on what the member needs to travel safely, such as an ordinary car or taxi, a wheelchair-accessible van with a lift or ramp, or a stretcher vehicle.
NEMT routing: NEMT routing is the dispatch work of turning a day's assigned trips into vehicle runs: which driver takes which rider, in what order, with pickup and drop-off times that fit the appointments. It is an operations task rather than a billing one, but it fixes the loaded miles and times each claim is paid on.
Net collection rate: Net collection rate is the share of collectable revenue a practice actually received, calculated by dividing payments collected by charges minus contractual adjustments for the same period, so that money the practice was never entitled to under its contracts is left out.
No Surprises Act: The No Surprises Act is the federal law, in effect since January 1, 2022, that limits what patients pay for emergency care, certain out-of-network care at in-network facilities and air ambulance services, and requires good faith estimates for uninsured and self-pay patients.
Notice of admission (NOA): A notice of admission (NOA) is the submission a Medicare home health agency sends to its Medicare contractor when it admits a patient, which opens the home health admission in Medicare's systems and must be on file before the agency's claims for that patient can be paid.

O

4 terms

OASIS: The Outcome and Assessment Information Set (OASIS) is the standard set of patient assessment items a Medicare home health agency must collect and send to CMS at set points in each admission. Medicare uses its items to group each 30-day period for PDGM payment, so the claim depends on it.
Occurrence code: An occurrence code is a two-character code, paired with a date, that tells the payer when a specific event affecting an institutional claim happened, such as an assessment, a hospital discharge or the day a patient's benefits ran out, reported in UB-04 form locators 31-34.
Open model EVV: Open model EVV is a state design for electronic visit verification in which the state offers its own EVV system, run in-house or by a contracted vendor, but also lets providers and managed care plans keep other EVV systems that meet its rules and send their visit data to the state.
Overpayment: An overpayment is money a payer paid that the provider is not entitled to keep. Medicare defines it as any funds a provider or supplier has received or retained under the Medicare statute to which, after applicable reconciliation, it is not entitled.

P

13 terms

Patient responsibility: Patient responsibility is the portion of a payer's allowed amount that the payer assigns to the patient instead of paying itself: the deductible, coinsurance and copay, plus any non-covered service the patient agreed to pay for. On the remittance it arrives under the PR group code.
Payer enrollment: Payer enrollment is the process of registering a provider or group with a health plan, Medicare or Medicaid so that the payer recognizes the provider's NPI, tax ID and location and will pay claims from a stated effective date.
Payer ID: A payer ID is the code that tells a clearinghouse and the EDI network which payer, or which part of a payer's business, should receive an electronic claim, eligibility check or claim status request. Payer IDs come from industry practice, not from a HIPAA standard.
Payment posting: Payment posting is the step where each payment and adjustment from a payer's remittance or a patient is recorded against the specific claim lines it applies to, so the account shows what was paid, what was written off and what is still owed.
PDGM: The Patient-Driven Groupings Model (PDGM) is the Medicare home health payment model in effect since January 1, 2020. It pays a national, standardized rate for each 30-day period of care, adjusted by one of 432 case-mix groups built from the patient's referral source, timing, diagnoses and function.
PDPM: The Patient Driven Payment Model (PDPM) is the case-mix system Medicare has used since October 1, 2019 to classify SNF patients in a covered Part A stay, setting the daily rate from five components: physical therapy, occupational therapy, speech-language pathology, nursing and non-therapy ancillaries.
PECOS: PECOS (Provider Enrollment, Chain, and Ownership System) is the online system CMS uses for Medicare provider enrollment. Providers and groups use it to enroll, reassign billing rights, update their records and revalidate.
Personal care services: Personal care services are Medicaid services for someone not living in a hospital, nursing facility, ICF/IID or institution for mental disease, authorized under a plan of treatment, given by a qualified worker who is not a legally responsible relative, and furnished at home or, if the state allows, elsewhere.
Place of service code: A place of service (POS) code is the code reported on professional claims to specify the setting where a service was rendered, such as an office, a facility or a patient's home via telehealth. CMS maintains the code set and payers apply their own reimbursement rules to it.
Prior authorization: Prior authorization is a payer's advance approval of a specific service, drug, procedure or supply for a specific patient, obtained before the service is delivered, without which the payer denies the claim regardless of medical necessity unless it allows a retroactive authorization.
Private duty nursing (PDN): Private duty nursing (PDN) is Medicaid's term for continuous nursing by an RN or LPN, under a physician's direction, for a patient who needs more individual care than a visiting nurse or a facility's nursing staff routinely provides, in the home, a hospital or a skilled nursing facility, as each state chooses.
Prompt pay law: A prompt pay law is a state statute or federal rule that requires a payer to pay or deny a clean claim within a set number of days after receiving it and to add interest or a penalty when it pays late.
Provider Transaction Access Number (PTAN): A Provider Transaction Access Number (PTAN) is the Medicare identification number that a Medicare Administrative Contractor assigns to an enrolled practitioner, group or supplier, separate from the National Provider Identifier that goes on claims.

R

10 terms

RAC audit: A RAC audit is a post-payment review of Medicare fee-for-service claims by a Recovery Audit Contractor, a CMS contractor that finds overpayments and underpayments, which the MAC then adjusts by recouping overpayments and paying underpayments.
Reassignment of benefits: Reassignment of benefits is a practitioner's authorization for an eligible group, organization or individual to submit claims and receive Medicare Part B payment for the services the practitioner provides as a member of that group or organization.
Recoupment: A recoupment is a payer's recovery of a payment it has decided was made in error, taken either as a refund the provider sends back or as an offset deducted from later remittances, with the original claim shown as reversed on the remittance advice.
Relative value unit (RVU): A relative value unit (RVU) is the measure the Medicare Physician Fee Schedule gives each service for physician work, practice expense and malpractice cost; adjusted for geography and multiplied by a dollar conversion factor, the RVUs set the payment amount.
Remittance advice: A remittance advice is the statement a payer sends with or ahead of a payment that lists, claim by claim and line by line, what was allowed, paid, adjusted and denied, with the reason codes for each adjustment. It arrives on paper or electronically as the 835 ERA.
Remittance advice remark code (RARC): A remittance advice remark code (RARC) is a code on an ERA or paper remittance that adds detail to a claim adjustment reason code or carries an informational message about the claim, so you know the specific reason behind a denial, reduction or hold rather than only its category.
Respite care: Respite care is short-term care and supervision for a person who cannot care for themselves, given so that the people who usually provide that care can be away or get relief. In Medicaid it is one of the services a home and community-based services waiver can cover.
Revalidation: Revalidation is the periodic renewal of a provider's or supplier's Medicare enrollment record, required to keep Medicare billing privileges active. CMS sets the cycle and the enrollment contractor sends the notice.
Revenue code: A revenue code is a four-digit code on each line of an institutional claim, form locator 42 on the UB-04 or data element SV201 on the 837I, that identifies the department or kind of service a charge belongs to, from an accommodation or a therapy visit to the line that carries a prospective payment code.
Risk adjustment: Risk adjustment is the method a payer uses to change what it pays a health plan for each member according to that member's expected cost, based on demographic factors such as age and on the diagnoses documented at face-to-face visits during the year.

S

4 terms

Secondary claim: A secondary claim is a claim sent to a patient's second insurance plan after the primary plan has paid, reporting the primary's allowed, paid and adjustment amounts so the secondary can decide what it owes on the remaining balance.
Split (or shared) visit: A split (or shared) visit is a Medicare evaluation and management (E/M) visit in a hospital or other facility setting that a physician and a nonphysician practitioner in the same group each perform part of, billed by whichever of them performed the substantive portion, with modifier FS.
Standing order: A standing order in non-emergency medical transportation is a single reservation and approval that covers a series of repeat trips for the same member to the same treatment, such as dialysis several times a week, instead of booking and approving each trip on its own.
Superbill: A superbill is the itemized record of a patient visit that lists the provider, patient, diagnosis codes, procedure codes, units and charges. The claim is built from it, or it is given to a self-pay patient to file with their own insurer.

T

6 terms

Targeted Probe and Educate (TPE): Targeted Probe and Educate (TPE) is a Medicare medical review program in which a MAC reviews a sample of a provider's claims for a specific item or service, typically 20 to 40 per round, and follows each round with one-on-one education.
Taxonomy code: A taxonomy code is a 10-character alphanumeric code from the Health Care Provider Taxonomy code set that classifies a provider by grouping, classification and area of specialization. It is selected on the NPI application and reported on claims when a payer requires it.
Timely filing limit: A timely filing limit is the window a payer gives you to submit a claim, counted from the date of service or the discharge date, after which the payer denies the claim and the practice usually absorbs the loss because a network contract bars billing the patient for it.
Trip attestation: A trip attestation is a signed or electronically captured confirmation that a non-emergency medical transportation (NEMT) trip took place as billed, usually the rider's signature, or a driver or facility statement, with pickup and drop-off details, which the broker or Medicaid program requires before paying.
Trip leg: A trip leg is one segment of a non-emergency medical transportation ride, from a single pickup point to a single drop-off point. A round trip to one appointment is two legs, and some Medicaid programs make the leg the unit of billing.
Type of bill (TOB): Type of bill (TOB) is the four-digit code in form locator 4 of the UB-04 that tells the payer, after a leading zero, what kind of facility is billing, what kind of care the claim covers, and where the claim falls in its sequence, from an original claim to a replacement or a void.

U

4 terms

UB-04: The UB-04, also designated the CMS-1450, is the standard paper claim form used by hospitals, skilled nursing facilities, home health agencies, hospices and other institutional providers to bill payers for facility services; the 837I is its electronic equivalent.
Unbundling: Unbundling is reporting the parts of a procedure as separate codes when a single code describes the whole service, or billing separately for work already included in another service's payment, so the claim pays more than the correct coding would.
Underpayment: An underpayment is a claim line a payer paid, but at less than its contract, its fee schedule or the law requires, after the patient's share and any valid reduction are taken into account.
Upcoding: Upcoding is billing a code that describes a more complex, more severe or more expensive service than the one actually performed and documented, so the claim pays more than the care supports.

V

2 terms

Value code: A value code is a two-character code paired with an amount on an institutional claim, reported in UB-04 form locators 39-41, that gives the payer a monetary or numeric fact it needs to process the claim, such as the area where home health care was given.
Void claim: A void claim is a request, sent with claim frequency code 8 and the payer's original claim number, that asks the payer to cancel a claim it has already processed, reversing the claim and taking back any payment made on it.

W

1 term

Write-off: A write-off is an adjustment that removes all or part of a balance from accounts receivable because it will not be collected, whether the reason is a payer contract, a denial that cannot be overturned, a documented hardship or a patient balance judged uncollectible.

X

1 term

X12: X12 is the standards organization, chartered by the American National Standards Institute, whose electronic data interchange formats carry US health care claims, remittances, eligibility checks and claim status, in the version 5010 implementation guides adopted under HIPAA.

Medical billing glossary

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