Medical billing glossary: terms billers use every day

A flat daily rate paid for each day a patient is in a program, such as residential treatment. Claims bundle the days together, instead of billing each encounter separately.

The X12 005010X214 response reporting claim level acceptance or rejection after the 999. It is not required under HIPAA, but billers read it to find claims rejected before the payer.

The Medicare rule that folds related outpatient services a hospital gave on the admission date and in the 3 days before it into the inpatient payment. Some hospitals use a 1-day window.

A federal drug pricing program that lets eligible hospitals and clinics buy certain outpatient drugs at discounted prices. Billing rules cover duplicate discounts and how claims are marked.

The federal rule that adds consent limits on sharing substance use disorder treatment records. It is stricter than HIPAA, so billing and records requests for these programs need extra care.

Medicare's method for turning total timed minutes in a day into billable 15-minute units for timed therapy codes, using a table to decide how many units the minutes support.

The X12 electronic institutional claim, the electronic version of the UB-04. Hospitals and other facilities send inpatient and outpatient claims to payers through it.

The X12 electronic professional claim, the electronic version of the CMS-1500. Physician and practitioner claims go to payers through it, usually by way of a clearinghouse.

An X12 acknowledgment returned for a submitted transaction set, reporting transaction level errors or confirming receipt without syntax errors. It is not required under HIPAA, but billers read it to confirm a file was accepted.

Money owed to a practice for services already provided, either by payers or by patients. Billers track it by age to see which claims are unpaid and need follow-up.

A professional association for medical coders and billers that offers coding certifications and training. Many employers look for AAPC credentials such as CPC when hiring coders.

A 2016 California law that limits patients to in-network cost sharing for non-emergency care by an out-of-network professional at an in-network facility. It sets the payment rate and a state dispute process.

The Advance Beneficiary Notice, CMS form CMS-R-131, which shifts financial liability to a Medicare fee-for-service patient when a service may not be covered. It works only if given before the service and signed.

An accountable care organization, a provider group that takes responsibility for the cost and quality of care for an enrolled MassHealth population. Billers confirm whether a member is in an ACO before billing.

A code reported only in addition to a primary procedure code, never alone. It captures extra work done during the same session and is usually listed with the base code on the claim.

Closing a defect by cutting nearby tissue and moving it over the gap. It is billed by defect size and body area, with CPT codes 14000 to 14350.

An additional documentation request, a letter from a Medicare contractor asking a provider to send records to support a claim under review. A missed response deadline usually leads to a denial.

Arizona Health Care Cost Containment System, Arizona's Medicaid program. Billers use AHCCCS rules and provider manuals for eligibility, claim submission and replacement claims.

AHCCCS Complete Care, or ACC, health plans cover physical and behavioral health together for most AHCCCS members, since October 1, 2018. Billers send those claims to the member's plan.

The apnea-hypopnea index, the average number of apneas and hypopneas per hour of sleep. Payers use it to judge the severity of sleep apnea and whether CPAP is covered.

The American Health Information Management Association, a professional body for health information and coding staff. It offers coding credentials and publishes standards for managing records and data.

Alabama Coordinated Health Network, one of Alabama Medicaid's two managed care programs. ACHNs operate in seven regions, so billers check the member's region and network.

The Alaska Medicaid claims and provider portal, where billing providers manage users, claims and remittance set-ups for each enrollment.

Treatment that gives a patient gradually increasing doses of an allergen extract to build tolerance. It is billed in two parts, preparing the extract and giving the injection.

The most a payer will recognize for a service under the contract or fee schedule. The payer pays the allowed amount less patient cost sharing, and the rest is a contractual adjustment.

The Alaska Medicaid Coordinated Care Initiative, a voluntary program from the state health department giving Medicaid members one-on-one case management.

The federal Anti-Kickback Statute, which makes it a crime to offer or take payment to generate referrals for services paid by federal health programs. Some arrangements are protected by safe harbors.

An ambulatory payment classification, a group of outpatient services alike in cost and clinical use. Medicare's OPPS pays a set amount for each APC, based on its relative weight and the conversion factor.

All Patient Refined Diagnosis Related Groups, the grouper North Dakota Medicaid uses to pay inpatient stays at in-state PPS hospitals. The diagnoses and procedures on the claim set the payment.

Arkansas Health and Opportunity for Me, the Arkansas Medicaid program that buys private health plan coverage, from Blue Cross Blue Shield or Ambetter, for eligible adults. Billers send claims to that plan.

An ambulatory surgical center, a facility that performs outpatient surgery without an overnight stay. Medicare pays it a facility fee under its own payment system, separate from the surgeon's fee.

An administrative services organization, which runs member and provider services for the state while the state stays the payer of record. In Connecticut, the state pays HUSKY claims.

Average sales price, the manufacturer-reported price that CMS uses to set Medicare Part B payment for most physician-administered drugs, usually ASP plus a set percentage.

A patient's written transfer of the right to insurer payment to the provider, so the plan pays the provider directly. Billers keep the signed form on file before billing the plan.

A physician or other practitioner who actively helps the surgeon during an operation. Medicare pays 16 percent of the surgical payment, where the code allows an assistant, using modifiers such as 80, 81 or 82.

A modifier showing a Medicare chiropractic claim is for active or corrective treatment, not maintenance. Billers add it to spinal manipulation codes or Medicare will not pay the service.

The average of the contracted commercial rates a plan pays for the same or similar services in a region. Under AB 72 the payment floor is the greater of this or 125 percent of Medicare.

The annual wellness visit, a Medicare preventive visit billed with G0438 for the first visit and G0439 for later ones. It is a planning visit, not a physical exam.

A business associate agreement, the written contract HIPAA requires between a covered entity and a business associate. It sets how the associate may use and must safeguard protected health information.

The part of a patient's balance the provider expects not to collect after reasonable collection efforts, even though the patient could pay. It differs from charity care, which is never expected to be paid.

Billing a patient for the difference between the provider charge and what the plan paid. The No Surprises Act bans it for emergency care and for out-of-network care at in-network facilities, unless an exception applies.

The fixed value assigned to each anesthesia procedure code to reflect its difficulty. It is added to time units and any modifying units to figure the anesthesia payment.

Several related out-of-network line items sent through federal IDR as one dispute and decided together in a single payment determination. Items must share the same payer and billing NPI or TIN, among other limits.

The code in UB-04 form locator 4 that tells the payer what kind of facility and claim this is, such as hospital inpatient, hospital outpatient, or a replacement claim. It uses three or four digits.

A biologic drug that is highly similar to an approved reference biologic, with no meaningful clinical difference. Biosimilars have their own HCPCS billing code and often cost less than the reference product.

Billing separately for services that a single, more comprehensive code already covers. NCCI edits exist to stop it. The opposite, bundling, is combining services under one code when the rules allow.

A person or company that handles patient health information for a covered entity, or on behalf of it, such as a billing company. Subcontractors that touch the data are business associates too.

Any weekday that is not a federal holiday. Open negotiation and federal IDR deadlines count in business days, so one miscounted day can end a dispute. Weekends and holidays never count.

A drug billing model where the practice buys the drug, stores it, gives it to the patient and bills the payer for it. The practice carries the cost until it is reimbursed.

Computer-aided dispatch, the software that logs an EMS call, the crew and the times. Billers use its call data to back up the trip details on the ambulance claim.

A payment model where a payer pays a fixed amount per member per month, no matter how many services the member uses. The practice carries the cost of care within that amount.

An online database, the CAQH Provider Data Portal, where providers keep one credentialing profile that many commercial plans use. The provider must attest to its data on a regular schedule so plans can credential them.

A claim adjustment reason code, the X12 code on a remittance that states why a payer adjusted a claim line, such as CARC 16 for missing information or CARC 45 for the contract adjustment.

Cardinal Care is Virginia's unified Medicaid program, covering both managed care and fee-for-service members. Billers confirm which delivery route a member uses before choosing where to send the claim.

Secondary diagnoses that raise the severity of an inpatient stay. A CC is a complication or comorbidity and an MCC is a major one. They move many cases to a higher-weighted MS-DRG tier.

Chronic care management, a Medicare service where the practice coordinates monthly care for a patient with two or more chronic conditions. It is billed once a month when time and consent requirements are met.

The CMS certification number, a six-digit number that identifies a Medicare-certified facility. Cost reports and facility enrollment use it, and its digits show state and provider type.

The California Department of Insurance, the agency that regulates insurers, including health insurance policies. It handles complaints about plans that fall under insurance law instead of the DMHC.

Clinical documentation integrity, the review in which staff ask clinicians to clarify unclear or incomplete notes, so the record supports the right diagnoses, severity and codes without leading the provider.

The Clinical, Etiology, Anatomy and Pathophysiology classification of venous disease, with clinical classes from C0 to C6. Payers use it to judge medical necessity for vein procedures.

State approval a West Virginia provider must obtain before adding or expanding services or exceeding capital thresholds. Billers and managers check it before a new service line is launched.

The neutral organization, certified by the Departments, that decides a federal IDR dispute. It reviews both final offers and must pick one, weighing the QPA and the other listed factors.

A continuous glucose monitor, a sensor that records glucose levels in the fluid under the skin over several days. Coverage depends on the patient's diabetes treatment and a documented need.

Community Health Automated Medicaid Processing System, the claims system for Michigan fee-for-service Medicaid. Billers use it to submit claims and manage Medicaid provider enrollment.

The process of turning every service, supply and drug a patient received into a billable charge line on the account. Missed or late charges become lost revenue or compliance risk.

The hospital master list of every item and service it can bill, with a charge, revenue code and HCPCS code for each. Claims draw charge lines from it, so errors there repeat on every claim.

Free or discounted care given to patients who cannot pay, based on the provider's financial assistance policy. It is written off when care is given or eligibility is found, not treated as bad debt.

The Children's Health Insurance Program, joint federal and state coverage for children in families whose income is above Medicaid limits. States run it, often through the Medicaid agency or managed care plans.

Software that checks a claim for errors before it goes to the payer, such as missing fields, invalid codes or edit conflicts, so problems are fixed before they cause a rejection or denial.

A claim with all the information a payer needs, and no errors, that can be processed without more information. State prompt pay laws and payer contracts define it, and payment clocks start from it.

The share of claims that go out with no errors and pass payer edits on the first submission, without needing correction. A higher rate means fewer rejections and faster payment.

A company that receives claims from a provider's system, checks them for format and data errors, and passes them to payers. It also returns acceptance reports and delivers remittances.

The Clinical Laboratory Fee Schedule, the Medicare payment schedule for laboratory tests. Each lab test code has a national payment amount that sets what Medicare pays.

The Clinical Laboratory Improvement Amendments, the federal rules that certify laboratories. A lab must hold the right CLIA certificate for the tests it performs and bills.

A per-unit fee Medicare pays for items and services tied to clotting factor products, built into the payment limit for the product billed by the provider or supplier.

The Connecticut Medical Assistance Program, the fee-for-service claims system and provider enrollment for HUSKY Health. Billers enroll and submit claims through it.

A care management organization, Georgia's term for a private health plan under contract with the state Medicaid agency. It delivers and pays for covered services, so billers send claims to it.

The Centers for Medicare and Medicaid Services, the federal agency that runs Medicare, works with states on Medicaid, and publishes the billing rules, fee schedules and code sets that most payers follow.

The professional claim form used by physicians, practitioners and suppliers. Its electronic version is the 837P, and the NUCC maintains the form. Place of service goes in item 24B.

The family of Medicare enrollment applications that providers and suppliers file to bill Medicare. Different forms cover physicians, organizations, reassignment of benefits, and changes to existing enrollments.

Coordination of benefits, the rules that decide which of a patient's plans pays first and which pays second. Claims go to the primary payer first, and the secondary payer sees the primary payment.

The percentage of the allowed amount that a patient pays after the deductible, such as 20 percent of a covered Medicare Part B service. A remittance reports it as PR-2.

A two-character UB-04 code in form locators 18 to 28 that reports a condition or event affecting how the claim is processed or paid, such as an observation or an outpatient-to-inpatient change.

A payment Medicare makes for a service while another payer, such as liability or workers' compensation insurance, may be responsible. Medicare can recover it once the other payer settles.

The part of a charge a provider must write off because the payer's contract or fee schedule allows less. It appears on the remittance as CARC 45 under group code CO.

The dollar amount that turns relative weights into a payment. On the physician fee schedule it multiplies the total RVUs, and under OPPS it multiplies the APC relative weight.

A coordinated care organization, an Oregon Medicaid plan that manages care for Oregon Health Plan members in a region. Billers send those members' claims to the CCO, not to the state.

A flat dollar amount a patient pays for a covered service, such as a visit, set by the plan. Providers usually collect it at the time of service, and it appears as PR-3.

Under HIPAA, a health plan, a health care clearinghouse, or a provider that sends standard electronic transactions such as claims. Covered entities must follow HIPAA privacy and security rules.

Current Procedural Terminology, the code set published by the American Medical Association that describes medical services and procedures. Claims use five-character CPT codes to report what a clinician did.

The payer's check of a clinician's license, training, work history and other background before it accepts the clinician into its network. It must finish before in-network claims can be paid.

A small rural hospital that meets Medicare conditions and is paid under special critical access rules instead of the standard hospital payment systems.

Care for a patient with a high chance of life-threatening decline, billed by time. CPT 99291 covers the first 30 to 74 minutes on a date, and 99292 covers each additional 30 minutes.

A claim reference number, the AHCCCS number that identifies a claim. It is required when a replacement claim is sent, so billers record it from the original.

A certified registered nurse anesthetist, an advanced practice nurse who gives anesthesia. A CRNA can bill Medicare directly or work under an anesthesiologist, which changes the modifiers used.

A measure of how long it takes to collect on average, found by dividing accounts receivable by average daily charges. A lower number means the practice is getting paid faster.

The amount a patient pays for covered care each plan year before the plan starts paying. A remittance reports it as PR-1, and billing the patient depends on checking eligibility first.

The share of submitted claims, or claim dollars, that payers deny. Tracking it by payer and denial reason shows where the billing process is losing revenue.

An ambulatory surgery center procedure that uses an implanted device whose cost offset exceeds 30 percent of the procedure cost. These cases follow separate payment and billing rules from ordinary surgical procedures.

The Delaware Medical Assistance Program, the operating arm of Delaware Medicaid, run by the Division of Medicaid and Medical Assistance. Billers use DMAP manuals and notices for claims rules.

Durable medical equipment, such as oxygen concentrators or wheelchairs, that a supplier bills to the DME Medicare Administrative Contractor. Orders and documentation requirements are strict.

Durable medical equipment, prosthetics, orthotics and supplies. This is the Medicare category for items such as wheelchairs, braces and oxygen gear, billed with HCPCS codes and strict ordering documentation.

The California Department of Managed Health Care, the agency that licenses and regulates health care service plans under the Knox-Keene Act. Providers can bring payment complaints against such plans to it.

Discharged not final billed, the work queue and dollar total of accounts where the patient has left but the claim has not been sent. A high or aging DNFB signals delays in coding or documentation.

The Diamond State Health Plan, Delaware's Medicaid managed care program, with DSHP Plus for older adults and people with physical disabilities. Billers send claims to the member's plan.

Diabetes self-management training, a Medicare outpatient education benefit that teaches patients to manage diabetes. It needs a referral from the treating practitioner and is billed with specific codes.

The Department of Vermont Health Access, which administers Vermont's publicly funded health insurance, including Vermont Medicaid and Dr. Dynasaur. Gainwell processes the claims.

Evaluation and management, the CPT visit codes that bill for a clinician's assessment and decision making in an office, hospital or emergency setting. The level depends on medical decision making or time.

Enhanced Ambulatory Payment Grouping, the system North Dakota Medicaid uses to pay outpatient lines at in-state PPS hospitals. Each billed line is grouped and priced under it.

Endobronchial ultrasound, a bronchoscopy that uses an ultrasound probe to sample lymph nodes or lesions near the airways. It has its own CPT codes and bundling edits with other bronchoscopy codes.

Electronic data interchange, the electronic exchange of claims and payment data between billers, clearinghouses and payers. Claims sent this way follow the standard X12 formats instead of paper.

The Iowa Medicaid electronic data interchange clearinghouse. Billers can send electronic claim files for Iowa Medicaid through it instead of using paper.

Electronic funds transfer, the payment a payer sends to a provider's bank account, usually matched to an ERA by a trace number. It replaces paper checks and speeds posting.

An electronic health record, the digital chart that holds a patient's history, orders and notes across care settings. Billers use its documentation and charge data to support coding and claims.

Checking before a visit that a patient's coverage is active and what it pays. Practices send an electronic inquiry to the plan and read the response, the 270 and 271 transactions.

Under the No Surprises Act, screening and stabilizing care for an emergency medical condition at a hospital emergency department or freestanding emergency department, including related ancillary services, and post-stabilization care in some cases.

The MO HealthNet web portal for fee-for-service claims, eligibility and remittance advices. Billers submit and track Missouri Medicaid claims there.

An electronic medical record, the digital version of a patient's chart within one practice. People often use the term interchangeably with EHR, though an EHR is meant to be shared across organizations.

The federal law requiring hospitals with emergency departments to give a medical screening exam and stabilizing treatment to anyone who asks, whatever the patient's insurance or ability to pay.

A minimally invasive procedure that seals a damaged vein using radiofrequency or laser heat. Payers cover it only when criteria such as symptoms, imaging and failed conservative care are documented.

An explanation of benefits, the statement a plan sends the member showing what was billed, what the plan allowed and paid, and what the patient owes. It is not a bill.

Explanation of Payment, Ambetter's name for the remittance statement. It shows what the plan paid, adjusted and denied on each claim, and billers post payments from it.

An electronic patient care report, the crew's chart of an EMS call. Billers build the ambulance claim from it, so it must support the service level and the medical necessity.

An exclusive provider organization plan that pays only for in-network care, except in emergencies, but usually needs no referral to see a specialist. Contracts and network status drive how claims are paid.

Early and Periodic Screening, Diagnostic and Treatment, the Medicaid benefit that covers screening, diagnosis and necessary treatment for enrollees under 21. It can cover services a state plan would otherwise limit.

An electronic remittance advice, the X12 835 file in which a payer reports claim payments, adjustments and denials. Billing systems post payments from it automatically, using CARC and RARC codes.

The federal Employee Retirement Income Security Act, which governs employer-sponsored benefit plans. Self-funded ERISA plans are generally outside state insurance law, and its claims rule sets the plan's appeal process.

An erythropoiesis-stimulating agent, such as epoetin alfa or darbepoetin alfa, a drug that stimulates red blood cell production. Medicare covers it only for certain conditions and requires lab values on the claim.

End-stage renal disease, kidney failure that needs regular dialysis or a transplant. Medicare pays for dialysis under a special bundled payment, with its own billing rules.

A required visit, in person or by telehealth, between the practitioner and the patient before the practitioner orders certain DME items. Missing or thin visit notes are a common reason for denial.

A federal law that makes it illegal to submit false claims to government health programs, including keeping an overpayment after learning of it. Penalties include repayment of damages and fines.

A financial assistance policy, the written policy a nonprofit hospital must have under IRS section 501(r) that sets who qualifies for free or discounted care and how patients apply.

A payer's or state's list of the maximum amount it will pay for each procedure code. Workers' compensation and many contracts pay the lesser of the billed charge or the fee schedule.

A payment model where the payer pays a separate amount for each service billed. Original Medicare pays this way, using the fee schedule for each code on the claim.

A dispute method where each side submits one payment offer and the decision maker must pick one of them, with no split. Federal IDR under the No Surprises Act works this way.

The contractor that processes and pays a state's fee-for-service Medicaid claims, handles enrollment and researches disputed payments. A claim counts as on time when this agency receives it.

The contractor that processes and pays fee-for-service Medicaid claims for the state. In Louisiana, Gainwell Technologies holds this role and applies claim edits and audits.

Florida Medicaid Management Information System, the claims system behind the Florida Medicaid Web Portal. Billers use the portal to submit claims, check eligibility and read remittances.

Fine needle aspiration, a biopsy that uses a thin needle to draw cells from a lump or organ such as the thyroid. Billing depends on the site and whether imaging guidance is used.

ForwardHealth is the Wisconsin Department of Health Services provider portal for Medicaid enrollment, handbooks and claims information. Billers use it as the main Wisconsin Medicaid billing site.

A code marking a claim as original, replacement or void. It is the third digit of the UB-04 bill type, or the CMS-1500 frequency code; 7 means replacement, 8 void.

A health plan where an insurance carrier takes the claim risk and follows state insurance law. State surprise billing rules usually apply to it, unlike self-funded employer plans.

Gainwell Technologies, the Rhode Island Medicaid fiscal agent that receives and pays fee-for-service claims and handles provider enrollment. It also holds that role in other states.

Georgia Medicaid Management Information System, the main web portal for Georgia Medicaid, PeachCare for Kids and waiver claims, eligibility and enrollment. Gainwell Technologies runs it as fiscal agent.

Georgia Families is Georgia's Medicaid and PeachCare for Kids managed care program, delivered through contracted care management organizations. Billers send most claims to the member's CMO.

The window of 0, 10 or 90 days in which Medicare's one payment for a surgical procedure covers the related care around it. Unrelated or return-to-surgery work needs modifiers to be paid.

A West Virginia program that exempts trusted practitioners from certain insurer prior authorization requirements, based on their past approvals. Billers check whether a practitioner qualifies before requesting authorization.

A written, itemized estimate of expected charges that a provider or facility must give an uninsured or self-pay patient before scheduled care. Final bills far above it can trigger the patient-provider dispute process.

The geographic practice cost index, an adjustment CMS applies to the work, practice expense and malpractice parts of an RVU, so the fee schedule payment reflects local costs in each Medicare locality.

The two-letter code on a remittance that says who is financially responsible for an adjustment. CO is contractual obligation, PR is patient responsibility, OA is other adjustment and PI is payer initiated reduction.

The national code set for items and services that CPT does not cover, such as drugs, supplies and equipment. Level II codes start with a letter, like J, G or S, and CMS maintains them.

The Colorado Department of Health Care Policy and Financing, the state Medicaid agency. Billers look to HCPF for Colorado Medicaid billing rules and provider bulletins.

HealthChoice Illinois is the statewide Illinois Medicaid managed care program. Most members belong to a managed care plan, so billers send claims to the member's plan instead of to HFS.

Healthy Connections Medicaid is South Carolina's Medicaid program, administered by the South Carolina Department of Health and Human Services. Billers follow its administrative and billing guide for claims and eligibility.

Michigan's Medicaid expansion program for low-income adults, run as comprehensive managed care. Billers send these members' claims to their health plan.

The cardiac surgeon and interventional cardiologist who together evaluate a patient and perform a TAVR procedure. Medicare coverage requires both to take part.

The HIPAA Eligibility Transaction System, the CMS system that returns Medicare eligibility details for a patient in response to a 270 inquiry, used to check coverage before billing.

The Healthcare Financial Management Association, a professional group for hospital and health system finance leaders. It publishes revenue cycle benchmarks such as days in A/R and clean claim rate.

New Jersey's Health Information Electronic Data Interchange Technology Act, P.L.1999 c.154. It is the state law that sets electronic claim and payment rules for insurers and providers.

The federal health privacy law. It sets rules for how covered entities and their business associates may use, share and protect patient health information, including billing data.

A Health Insurance Prospective Payment System code, a five-character code on home health claims under revenue code 0023 that reflects the case-mix group used to set the payment.

A health maintenance organization plan that generally covers care only from its network and often requires a primary care referral. Out-of-network care is usually not paid except in emergencies.

The federal rule in 45 CFR part 180 requiring hospitals to post their standard charges publicly, including payer-specific negotiated rates, in a machine-readable file and a shoppable format.

HUSKY Health is Connecticut's Medicaid and CHIP program, run by the Department of Social Services. Billers use Connecticut's provider rules and the CMAP system for HUSKY claims.

The US diagnosis code set, maintained by CDC and NCHS, that describes a patient's conditions on claims. Codes have 3 to 7 characters and are updated each October 1.

The procedure code set used to report inpatient hospital procedures. Codes have seven characters, and CMS maintains it. Outpatient and professional claims use CPT and HCPCS instead.

An internal control number, the number the payer assigns to a processed claim. Billers use it to search for the claim and to reference it on follow-up or replacement claims.

The federal process where a certified entity picks between a provider's and a plan's payment offer for an out-of-network bill covered by the No Surprises Act, after open negotiation fails.

The non-refundable fee each party pays the federal IDR operator to start a dispute. The current rule sets it at $15 per party for disputes initiated on or after June 11, 2026.

Indiana Health Coverage Programs, Indiana's Medicaid program, run by the Family and Social Services Administration. Billers use the IHCP provider rules and portal for eligibility, claims and enrollment.

The web portal where IHCP providers submit claims, check eligibility and send secure correspondence. It is the main working tool for Indiana Medicaid billing.

Iowa Medicaid Portal Access, the Iowa Health and Human Services provider web portal. Billers use it for Medicaid provider services such as eligibility and claims information.

Illinois Medicaid Program Advanced Cloud Technology, the HFS system where providers enroll and revalidate with Illinois Medicaid. A claim cannot be paid if the billing provider's IMPACT enrollment is not current.

A Medicare rule that lets a physician bill, under their own NPI, services staff perform in a noninstitutional setting as part of the physician's course of treatment, under the required supervision.

A state-licensed emergency facility that is geographically separate from a hospital and not a hospital department. The No Surprises Act treats it like a hospital emergency department for balance billing and out-of-network payment.

The practitioner's order that admits a patient to inpatient status. Medicare requires it, and it must be in the record before discharge, since inpatient payment starts only from a valid order.

The Medicare list of procedures that are paid only when performed on an admitted inpatient. CMS is phasing it out, so some procedures now can be billed as outpatient services.

Integrated Care Network, one of Alabama Medicaid's managed care programs, alongside the Alabama Coordinated Health Network. Billers confirm a member's program before sending a claim.

An intensive outpatient program, a structured mental health or substance use program requiring fewer weekly hours than PHP. Medicare has paid for it since January 1, 2024, at 9 hours a week minimum.

A commercial payer's approval of an intensive outpatient or partial hospitalization program as a site of care (facility level), plus the enrollment of each clinician who treats its members (individual level). Each plan sets its own requirements. See IOP and PHP credentialing.

Iowa Health Link is Iowa's Medicaid managed care program. Most members are enrolled with a managed care plan, so billers confirm the member's plan before sending a claim.

An inpatient psychiatric facility, a psychiatric hospital or a distinct psychiatric unit of a hospital. Medicare pays it a per diem rate under the IPF payment system.

The inpatient prospective payment system, Medicare's method for paying acute care hospitals a set amount per inpatient discharge, based on the MS-DRG, with adjustments for the hospital's wage index and other factors.

The Louisiana Medicaid screening program for children. Its claims have a 60-day filing window from the date of service, shorter than the 12 months for other claims, so billers work them separately.

The Knox-Keene Health Care Service Plan Act of 1975, the state law the DMHC enforces on health plans. It sets California's claim payment and licensing duties for those plans.

A modifier that tells Medicare the therapy services are medically necessary once the patient's spending passes the annual threshold. Without it, claims above the threshold are denied.

The web-based system Kentucky Medicaid names on its provider pages for checking member eligibility and looking up members. Billers use it, or the voice response line, before billing.

The South Dakota Medicaid web tool for uploading 837 claim files and downloading 999, 835 and status files. Billers use it to send batches and read responses.

A local coverage determination, a rule a MAC writes for its jurisdiction on when Medicare covers an item or service. A billing and coding article lists the codes that meet it.

A reduced per-visit payment Medicare makes when a home health period has fewer visits than the threshold. Agencies track visit counts so a short period is not paid as a full one.

A Medicare Administrative Contractor, the private company CMS pays to process Medicare Part A and Part B claims, enroll providers and handle first-level appeals for a regional jurisdiction.

The Medicare Access and CHIP Reauthorization Act of 2015, the law that created MIPS and advanced payment model tracks for Medicare Part B clinician payment.

The MUE adjudication indicator, a number on each MUE that says how the limit is applied: MAI 1 per claim line, and MAI 2 or 3 as a total for the whole date of service.

MaineCare is Maine's Medicaid program, administered by the Maine Department of Health and Human Services. Billers follow its rules for eligibility, filing and payment on MaineCare claims.

MassHealth is the Massachusetts Medicaid program. Billers working with it follow its 90-day rule for fee-for-service claims and its online claim submission through the Provider Online Service Center.

Montana Access to Health, the secure Montana Healthcare Programs provider web portal. Billers use it to check eligibility, look up claim status and read remittance advice.

The Medicare Beneficiary Identifier, the randomly assigned number on a patient's Medicare card that replaced the Social Security based number and goes on claims and eligibility checks.

A managed care organization, a plan under contract with the state Medicaid agency to pay claims for its enrolled members. Billers send those claims to the plan, not to the state.

Medical decision making, the part of a note that shows the problems addressed, the data reviewed and the risk of the patient's management. It is one basis for choosing an E/M level.

MEDI, the Illinois Department of Healthcare and Family Services web system for checking member eligibility and submitting fee-for-service Medicaid claims. Billers check eligibility here before each visit.

Medi-Cal is California's Medicaid program, run by the Department of Health Care Services. Billers confirm whether a member is in a managed care plan or fee-for-service before billing.

The middle value of a plan's contracted rates for the same service, specialty and region. It is the base for the qualifying payment amount, calculated under 45 CFR 149.140 from rates in effect in 2019.

The joint federal and state health coverage program for people with low income. States set most billing rules within federal floors, including filing limits, covered services and how managed care plans pay.

A payer's test that a service is appropriate and needed for the patient's condition, under accepted practice. Coverage rules, such as LCDs, and the documented diagnosis decide whether a claim passes.

Medicare Part C, where private plans deliver Medicare benefits and CMS pays them a set amount per member. They have their own networks, authorization rules and appeals, and the No Surprises Act does not apply.

A claim for a member eligible for both Medicare and Medicaid, billed to Medicare first and then to Medicaid with the Medicare payment information. Medicaid pays only what remains under its rules.

The Medicare Physician Fee Schedule, the CMS list of payment amounts for clinician services. Each code's amount comes from its RVUs, the GPCI for the locality and the conversion factor.

The Virginia Medicaid Enterprise System, the Department of Medical Assistance Services platform that hosts the provider portal, training and memos. It launched April 4, 2022.

The Medicaid Eligibility Verification System, Louisiana's tool for checking date-specific eligibility, health plan links, other insurance and service limits. Billers check it for each patient.

The Mental Health Parity and Addiction Equity Act, the federal law that says a plan cannot limit mental health or substance use benefits more strictly than its medical and surgical benefits.

The HIPAA rule that staff and vendors should use, share or request only the least amount of patient information needed for the task. Billing work is limited to the data it requires.

The Merit-based Incentive Payment System, a Medicare program that raises or lowers Part B payments to clinicians based on a final score from reported quality, cost and other measures.

MississippiCAN, also MSCAN, is Mississippi's Medicaid managed care program, delivered through coordinated care organizations alongside CHIP. Billers send members' claims to the member's plan.

Medicaid Management Information System, the state system that holds eligibility and processes fee-for-service Medicaid claims. Each state names its own, such as PRISM in Utah.

The Oregon MMIS Provider Portal at www.or-medicaid.gov, where billers check Oregon Health Plan eligibility. It shows eligibility history up to 13 months and no future dates.

Medical nutrition therapy, individual counseling by a registered dietitian or nutrition professional for conditions such as diabetes or kidney disease. Medicare covers it with a referral from the treating physician.

A two-character add-on to a procedure code that gives the payer more information, such as a procedure done on one side, by a certain provider, or separately from another service.

The Medicare Outpatient Observation Notice, a CMS form hospitals must give a Medicare patient who has been in observation more than 24 hours, explaining that they are an outpatient and what that means.

Mountain Health Trust is West Virginia's Medicaid managed care program, run by the Bureau for Medical Services Office of Managed Care. Billers send members' claims to their managed care plan.

The Medicare Severity diagnosis related group, the single group CMS assigns to each inpatient discharge from diagnoses, procedures, age, sex and discharge status. Its relative weight drives the inpatient payment.

A multiple sleep latency test, a series of daytime naps that measures how quickly a patient falls asleep. It helps diagnose conditions such as narcolepsy and is billed with its own code.

Medicare Secondary Payer, the federal rules that make Medicare pay second when another source, such as an employer plan, liability or workers' compensation, is responsible first. Providers must ask the MSP questions.

A medically unlikely edit, the most units of a code Medicare expects for one patient on one date of service. A claim line above the limit is cut or denied.

The National Correct Coding Initiative, a CMS program whose claim edits stop Medicare from paying for codes that should not be reported together or in excess units. Files update each quarter.

A national coverage determination, a CMS decision on whether Medicare covers an item or service nationwide. It binds all MACs, and an LCD can only clarify or fill gaps around it.

The North Carolina Medicaid claims processing and provider enrollment system, used for NC Medicaid Direct. Billers submit fee-for-service claims and manage provider enrollment there.

The National Drug Code, the 11-digit number on a drug label that identifies the product. Many payers require it on claims for drugs, alongside the billing code.

The national standard for EMS data. Agencies report their patient care records in this format, and the same records feed the billing data for ambulance claims.

The share of money a practice collects out of what it is allowed to collect after contractual adjustments. A rate near 100 percent means nearly all allowed payments were collected.

NJ FamilyCare is New Jersey's name for its Medicaid program. Billers who see this name on a card or portal are dealing with New Jersey Medicaid coverage.

The New Jersey Medicaid Management Information System, used by the state's fiscal agent to process Medicaid claims. It is the claims system behind New Jersey fee-for-service Medicaid billing.

Auto insurance, set by state law, that pays an injured person's medical costs regardless of who caused the crash. It is usually primary over health coverage and has its own forms and limits.

The Notice of Admission, a home health filing sent on type of bill 032A within five calendar days after the admission date. One NOA covers all periods until discharge.

Notice of Election, the hospice claim-format notice that creates the Medicare election period. It is due within 5 calendar days of admission, so billers send it promptly.

A provider or facility with no contract with the patient's plan. Payment follows the plan's out-of-network rules, and the No Surprises Act, or a state law, can limit what the patient owes.

The written notice that opens the 30-business-day negotiation period. It must carry the provider's offer and identify the claim, and it goes to the payer within 30 business days of the first payment or denial.

The national provider identifier, the 10-digit number that identifies a provider or facility on claims. Individuals have a Type 1 NPI and organizations have a Type 2 NPI.

A nonquantitative treatment limit, a non-numeric plan limit such as prior authorization or step therapy. Under parity law, a plan cannot apply it more strictly to mental health care than to medical care.

The National Uniform Billing Committee, which maintains the UB-04 institutional claim form and its code sets, such as revenue codes, condition codes and type of bill.

The National Uniform Claim Committee, which maintains the CMS-1500 professional claim form and its instructions, and the provider taxonomy codes used on claims.

The Outcome and Assessment Information Set, the patient assessment that home health agencies complete to set the patient's function level. Its results feed the case-mix group used for payment.

Outpatient care, billed by the hour, that a hospital gives while deciding whether a patient needs inpatient admission. The patient owes Part B coinsurance, not the Part A deductible, and the stay is not inpatient.

A UB-04 code in form locators 31 to 36 that reports a dated event tied to the claim, such as an accident date or the date coverage ended, which payers use to apply rules.

The Oklahoma Health Care Authority, the agency that runs SoonerCare. Billers use its published policies and rules for filing limits, claim payment and provider requirements.

The Rhode Island Office of the Health Insurance Commissioner, which protects consumers of commercial health insurance. Complaints about commercial plans in Rhode Island go there.

The HHS Office of Inspector General, the federal office that audits and investigates fraud, waste and abuse in federal health programs and can exclude providers from participating.

A federal program that tests and certifies that electronic health record software meets national technical standards. Certified EHR technology is often required for quality and incentive programs.

A 30-business-day period of direct talks between provider and payer on an out-of-network bill. It must happen before either side can start federal IDR, and it opens with a written notice.

The outpatient prospective payment system, Medicare's method for paying hospitals for outpatient services. It pays predetermined amounts by APC, with many supporting items packaged into the main service.

The Oregon Health Plan, Oregon's Medicaid program. Fee-for-service claims have a 12-month filing limit, and billers verify eligibility and plan assignment on the date of service.

Obstructive sleep apnea, a condition where the upper airway repeatedly collapses during sleep. Diagnosis and treatment such as CPAP depend on sleep testing and documented severity.

An opioid treatment program, a SAMHSA-certified and Medicare-enrolled program that treats opioid use disorder. Medicare pays it weekly bundled payments that cover medication and related services.

The most a patient pays in a plan year for covered in-network care through deductibles, copays and coinsurance. After it is reached, the plan pays covered services in full.

In Alabama Medicaid, a clean claim that the fiscal agent did not receive on time is denied as outdated. An administrative review request must reach Medicaid within 60 days of that date.

Money a provider received from Medicare or another payer that it was not entitled to. Under the 60-day rule, identified overpayments must be reported and returned within the required period.

The Protecting Access to Medicare Act, the law that ties Medicare clinical laboratory fee schedule rates to what private payers pay. Labs report private payer rates to CMS under it.

A provider or facility with a contract with the patient's plan, bound to its negotiated rates and billing rules. The patient owes only the plan's cost sharing, such as copay, coinsurance and deductible.

Provider-Led Arkansas Shared Savings Entity, the Arkansas Medicaid managed care program for people with complex behavioral health needs or developmental disabilities. Billers send claims to the member's PASSE.

The two-digit UB-04 code in form locator 17 that reports where the patient went at discharge, such as home or a skilled nursing facility. A wrong code can change payment, such as through transfer policies.

The share of an allowed amount the patient owes, such as deductible, copay or coinsurance. A remittance reports it under group code PR, like PR-1 for deductible.

The federal process, called PPDR, that lets an uninsured or self-pay patient dispute a final bill that is $400 or more above the good faith estimate. A dispute entity decides, and collections pause meanwhile.

Applying to a payer so a practice or clinician can bill that plan, and getting set up with the right identifiers and contract. It is separate from credentialing, which verifies qualifications.

The number a clearinghouse uses to route electronic claims to the correct payer. A wrong payer ID sends the claim to the wrong place or causes a rejection.

A Medicare fee schedule field that shows whether a code can be split into a professional component, the physician's reading, and a technical component, the equipment and staff.

Primary care case management, a Medicaid model where each member is attached to a primary care provider who coordinates care. Montana's PCMT program is a PCCM model.

The South Dakota Medicaid general care management program that assigns each member a designated primary care provider. Billers check the assignment because it can affect which provider is paid.

The Patient-Driven Groupings Model, the Medicare home health payment system that pays by case mix for each 30-day period of care instead of by therapy visits.

Patient Driven Payment Model, the case-mix payment model CMS uses for Medicare Part A skilled nursing stays. Its HIPPS code has five positions, built from patient characteristics.

The Provider Enrollment, Chain and Ownership System, the CMS online system for Medicare enrollment. Providers must be enrolled in it, and ordering and referring providers must appear in it for claims to pay.

A pulmonary function test, a breathing test such as spirometry, lung volumes or diffusing capacity that measures how well the lungs work. Each test is billed with its own CPT code.

Protected health information, meaning individually identifiable health details held or sent by a covered entity or business associate. Claims, account numbers and diagnoses tied to a patient all count.

A partial hospitalization program, a day program of intensive mental health treatment offered by a hospital or community mental health center instead of inpatient care. Medicare requires at least 20 hours of services a week.

Personal injury protection, auto coverage that pays accident-related medical bills no matter who was at fault. In no-fault states it is usually the primary payer for crash injuries.

A two-digit code, reported in CMS-1500 item 24B, that says where the service was given, such as POS 11 for an office or POS 23 for an emergency room. It sets the payment rate.

The written treatment plan for outpatient therapy, which a physician or practitioner certifies. Billers confirm it is signed and current before billing the therapy services delivered under it.

Software that handles scheduling, patient registration, charge entry, claims and billing for a practice. It often works alongside the EHR, which holds the clinical record.

The MassHealth Provider Online Service Center, where non-dental, non-pharmacy MassHealth claims are submitted online, singly or in batches. Billers also use it to check claim status by internal control number.

Care a patient needs after an emergency condition is stabilized. Under the No Surprises Act it counts as emergency care, and balance billing stays banned, unless the patient gives a valid notice and consent.

A preferred provider organization plan that pays in-network and out-of-network care, with lower patient cost sharing in network. It usually does not require a referral to see a specialist.

A one-character flag on each inpatient diagnosis saying whether the condition was present when the admission order was written. Payers use it to identify hospital-acquired conditions and adjust payment.

The condition found after study to be chiefly responsible for the inpatient admission. It is the first diagnosis on the claim and the starting point for MS-DRG assignment.

Approval a payer requires before a service, drug or procedure is performed. Without it on file, the payer can deny the claim even when the care was medically necessary.

Provider Reimbursement Information System for Medicaid, Utah's Medicaid claims system. It replaced Utah's earlier MMIS in April 2023, and billers submit and track fee-for-service claims there.

State law that sets how quickly insurers must pay or deny a clean claim and what interest or penalty applies when they are late. Deadlines and penalties differ from state to state.

Any claim documentation an insurer receives that asks for payment. In Montana it starts the prompt pay clock, so billers keep proof of the date the insurer received it.

A Medicare status that lets a hospital bill an off-campus or on-campus department as part of the hospital, using the hospital outpatient rules under 42 CFR 413.65.

ProviderOne is the Washington Health Care Authority's web portal and claims system for Apple Health. Billers use it for eligibility checks, claim submission and remittance advice.

The Provider Services Solution, the Virginia Medicaid Enterprise System module where providers enroll in Virginia Medicaid and revalidate. Billers watch revalidation dates here so claims are not rejected for lapsed enrollment.

Polysomnography, an overnight sleep study that records sleep stages, brain waves, breathing and other body signals. It is billed with codes that depend on the setting and the number of channels recorded.

The provider transaction access number, an identifier a MAC assigns a provider after Medicare enrollment. It links the provider's NPI to its billing and payment records at that contractor.

A procedure-to-procedure edit, an NCCI rule pairing two codes. Medicare pays the Column One code and denies the Column Two code unless an allowed modifier is reported and documented.

The Qualified Independent Contractor, a reviewer that decides the second level of a Medicare appeal, called reconsideration, when the redetermination does not go in the provider's favor.

A quality improvement organization, a contractor CMS pays to review Medicare care and appeals. Beneficiary and Family Centered Care QIOs handle patient complaints and discharge or admission status appeals.

The qualifying payment amount, a plan's median contracted rate for the same service, specialty and region, indexed each year. It sets patient cost sharing and is one of the factors a certified IDR entity weighs.

A Marketplace health plan that meets federal certification standards. Billers see it on Ambetter and other exchange cards and apply the plan's own rules for authorization and filing.

A modifier that marks a laboratory test as CLIA-waived. Labs holding only a certificate of waiver need it on waived-test claims so the payer does not deny them.

A recovery audit contractor, a company CMS pays to find improper Medicare payments, both overpayments and underpayments, through claim reviews. Providers can appeal its findings.

A remittance advice remark code, an X12 code that adds detail to a CARC, such as which field is missing. Some CARCs, like 16, require a RARC. Together they explain a denial or adjustment.

Revenue cycle management, the full process from scheduling and eligibility through coding, claims, payment posting, denials and collections. It covers every step that turns care into payment.

A payer taking back money it paid earlier, usually by deducting it from later payments after finding an overpayment. Appeal deadlines can matter before recoupment begins.

The first level of a Medicare fee-for-service appeal, filed with the Medicare contractor that made the initial decision, within 120 days of the initial determination notice.

A request from one clinician, often the primary care physician, sending a patient to a specialist. Some plans, such as HMOs, pay specialist claims only when a valid referral is on file.

A rejection means the claim failed front-end edits and was never accepted, so no payment clock starts. A denial means the payer accepted and processed it, then refused payment, and appeal rights apply.

The payer's statement of how claims were paid, adjusted or denied, sent to the provider with or ahead of payment. The electronic version is the ERA, and the paper version is called a remit.

The independent third-party entity the Georgia Office of Commissioner of Insurance contracts with to arbitrate out-of-network payment disputes under Georgia's Chapter 20E.

A four-digit UB-04 entry in form locator 42 that names the department or service line of each charge, such as emergency room or pharmacy. It must match the chargemaster line and the HCPCS code.

The online portal for Rhode Island Medicaid provider enrollment, eligibility, claim status and remittance advice. Billers work in it daily for fee-for-service claims.

RIte Share is a Rhode Island premium assistance program that helps pay for employer health coverage. Billers handle it as other insurance that pays before Medicaid.

Remote patient monitoring, where devices send readings such as weight, blood pressure or pulse oximetry to the practice for review. Billing depends on device use, set-up and monthly clinical review time.

Radiological supervision and interpretation, the imaging guidance and image reading that some procedure codes already include. Billing it separately when it is bundled is a common edit error.

A relative value unit, the weight CMS gives a service on the physician fee schedule to reflect its work, practice expense and malpractice cost. Payment is the total RVUs times a conversion factor.

The free browser-based tool from the South Carolina Department of Health and Human Services for Medicaid claims, eligibility, claim status and remittance advice. It is the day-to-day billing portal.

An employer health plan where the employer pays claims from its own funds, often using an insurer only to administer it. State insurance laws, like prompt pay, generally do not reach these plans.

Medicare policy that narrows the payment gap between hospital outpatient departments and physician offices for the same service, so location changes the payment less.

A graft-like product applied to a wound to help it heal. Medicare pays for it under the 2026 physician fee schedule as an incident-to supply, not as a separately paid skin graft product.

Statewide Medicaid Managed Care, Florida's Medicaid managed care program run by the Agency for Health Care Administration. Most members are enrolled in a plan, so claims go to the plan, not the state.

SoonerCare is Oklahoma's Medicaid program, run by the Oklahoma Health Care Authority. Its fee-for-service timely filing limit is 6 months from the date of service for dates of service on or after July 1, 2015.

SoonerSelect is the Oklahoma Health Care Authority's Medicaid managed care program. Billers check whether a member is enrolled in a SoonerSelect plan before choosing where to send the claim.

A state law that sets how an out-of-network payment is determined. For the services it covers, it controls in place of the federal No Surprises Act payment process.

A hospital or facility E/M visit that a physician and a nonphysician practitioner of the same group perform together. Medicare bills it under whoever did the substantive portion of the visit.

The last day a Nevada Medicaid claim can reach the fiscal agent, 180 or 365 days depending on the claim. Claims received after it are denied as late.

The federal physician self-referral law. It limits a physician from referring Medicare patients for certain designated health services to an entity with which the physician has a financial relationship.

A state law that sets how out-of-network emergency and facility bills are paid and limits patient cost sharing. It controls only if it meets the federal definition and covers the plan, otherwise federal IDR applies.

A letter on each HCPCS code in the OPPS payment files that tells how, or whether, Medicare pays that code, for example separately, packaged into another service, or not paid under OPPS.

A payer rule that a patient must try a lower-cost drug first, and only qualifies for the higher-cost drug if the first one fails. Exceptions usually need documentation from the prescriber.

A motion segment of the spine where alignment, movement integrity or function is altered although joint surfaces stay in contact. It is Medicare's definition for chiropractic coverage.

A payer's right to recover what it paid for a patient's care from a third party who caused the injury, such as an auto insurer. It can lead to payment holds and recoupment requests.

An unexpected out-of-network bill a patient receives after emergency care or after care from an out-of-network provider at an in-network facility. The No Surprises Act limits what the patient can be charged.

A standard written order, the treating practitioner's order for a DME item that the supplier must have on file. It lists the patient, the item, the date and the practitioner.

A ten-character code from the NUCC taxonomy list that describes a provider's type and specialty. Claims and enrollment records carry it, and a mismatch with the NPI record can cause rejections.

Transitional care management, billed with 99495 or 99496, covers a patient's first 30 days after leaving a hospital or similar stay. It requires contact and a visit within set deadlines.

A transaction control number, the number Washington's ProviderOne assigns to each claim. Billers keep it because it proves the original claim was received on time when a late resubmission is questioned.

A physician who supervises residents. Medicare pays for the service under the fee schedule only if the teaching physician was present for the key or critical portion and the note says so.

TennCare is Tennessee's Medicaid program, run by the Division of TennCare. Most claims go to a managed care plan, so billers check the member's plan before billing.

TennCare III is the Tennessee Medicaid demonstration, Project No. 11-W-00369, under which TennCare runs as a single statewide managed care system. It explains why most TennCare claims go to plans.

A Texas process run through the Texas Department of Insurance where a facility's out-of-network balance bill can go to mediation between the facility and the health plan.

The measure of anesthesia time in a payment calculation, typically one unit per 15 minutes. Billers add time units to the base units to find the total.

A CPT code defined by direct, one-on-one time, usually in 15-minute units. Therapy billing counts the time spent on each timed code to decide how many units to report.

The deadline after the date of service by which a payer will still accept a claim. It varies by payer and contract, and a claim filed after it is usually denied.

The taxpayer identification number, the federal tax ID a provider bills under. Payers pair it with the NPI to pay the right entity and report income on a Form 1099.

Adjusting the pressure of a CPAP device during a sleep study to find the setting that keeps the patient's airway open. It may be billed separately or as a split-night study.

Third party liability, meaning another insurer or source that owes payment before Medicaid. Billers bill the other payer first and send Medicaid the result, as Oregon's rules require.

The health program for active duty and retired military members and their families. Regional contractors process claims and appeals, and TRICARE For Life pays after Medicare.

Turquoise Care is New Mexico's Medicaid managed care program, which began July 1, 2024. Billers send members' claims to the managed care plan instead of the state.

The New Mexico Medicaid fee-for-service claims system, which replaced Omnicaid and the Provider Web Portal. Billers use it for claims that are paid by the state directly.

The Medicare benchmark that an inpatient admission is generally appropriate when the admitting practitioner expects the patient to need hospital care across at least two midnights, and documents that expectation.

The institutional claim form, also called CMS-1450, that hospitals and facilities use for inpatient and outpatient claims. Its electronic version is the 837I, and the NUBC maintains the form.

Reporting a higher-paying code than the documentation supports. Downcoding is the reverse, either by the biller or by a payer lowering the level. Both are audit targets and cost revenue or create liability.

A unified program integrity contractor, which CMS pays to investigate suspected Medicare and Medicaid fraud and abuse. Its records requests carry a shorter response time than most other reviews.

A UB-04 code in form locators 39 to 41, paired with an amount, that reports a number the payer needs, such as prior payments or covered days. The code says what the amount means.

A payment approach that ties part of the payment to quality, cost or outcome measures instead of only to the volume of services billed. MIPS is one Medicare example.

Vaccines for Children, the federal program that supplies publicly purchased vaccines at no charge to enrolled providers for eligible children. Billers charge an administration fee, not the vaccine itself.

The Women's Health and Cancer Rights Act, a federal law that requires group health plans covering mastectomy to also cover reconstruction, surgery on the other breast for symmetry, prostheses and complications.

Insurance that pays medical costs and lost wages for work-related injuries, regulated by each state. It is primary over health plans and Medicare, and uses its own fee schedules and forms.

A reduction of an account balance that the provider will not collect, such as a contractual adjustment, a charity care discount or an uncollectible balance. It leaves the receivable without a payment.

The standards body whose electronic formats are used for health care transactions such as claims, eligibility inquiries and remittances. Billing software exchanges data with payers in X12 files.

The standard electronic transactions for eligibility. The 270 is the inquiry a practice sends to a plan, and the 271 is the plan's response with coverage and benefit details.