A

Accounts Receivable (AR): The total amount of money owed to a healthcare provider for services rendered that has not yet been paid by patients or insurance companies. Let us manage your accounts receivable effectively with our Accounts Receivable Follow-Up and Management Services.

Adjudication: The process by which an insurance payer reviews a claim and determines the amount of payment, if any, to be made.

Allowed Amount: The maximum amount an insurance company will pay for a covered healthcare service. Also known as the allowable charge, eligible expense, or negotiated rate.

 

B

Balance Billing: The practice of billing a patient for the difference between the provider’s charge and the insurance company’s allowed amount.

Bundling: The practice of combining multiple healthcare services into a single payment or charge.

 

C

Capitation: A payment arrangement where a healthcare provider is paid a fixed amount per patient for a specified period, regardless of the number of services provided.

Claim: A request for payment submitted to an insurance company by a healthcare provider for services rendered to a patient. Ensure accurate claim submissions with our Medical Billing Services.

Clearinghouse: A third-party organization that processes and transmits medical claims from healthcare providers to insurance payers.

Coinsurance: The percentage of the cost of a healthcare service that a patient is responsible for paying after the deductible has been met.

Co-payment (Copay): A fixed amount a patient pays for a healthcare service at the time of the visit, as determined by their insurance plan.

D

Deductible: The amount a patient must pay out-of-pocket for healthcare services before their insurance begins to cover costs.

Denial: A refusal by an insurance company to pay for a healthcare service, often due to errors in the claim or lack of coverage.

 

E

Electronic Health Record (EHR): A digital version of a patient’s paper chart, containing their medical history, diagnoses, treatments, and more. Explore the benefits of EHR integration with our Electronic Health Records Integration Services.

Explanation of Benefits (EOB): A statement from an insurance company detailing what services were covered, the amount paid, and any patient responsibility.

 

F

Fee-for-Service (FFS): A payment model where healthcare providers are paid for each service performed, rather than a fixed amount per patient.

 

G

Global Period: A time frame after a surgical procedure during which all necessary follow-up care is included in the initial payment for the surgery.

 

H

Healthcare Common Procedure Coding System (HCPCS): A set of codes used to describe medical procedures and services for billing and documentation purposes.

HIPAA (Health Insurance Portability and Accountability Act): A federal law that sets standards for protecting sensitive patient information and ensuring privacy.

 

I

ICD-10 (International Classification of Diseases, 10th Revision): A coding system used to classify and code all diagnoses, symptoms, and procedures.

Insurance Payer: An organization, such as an insurance company or government agency, that pays for healthcare services.

 

M

Medical Necessity: A healthcare service or procedure that is deemed necessary for the diagnosis or treatment of a patient’s condition.

Modifier: A two-character code used to provide additional information about a medical procedure or service, indicating that it was altered in some way.

 

N

National Provider Identifier (NPI): A unique identification number assigned to healthcare providers in the United States for billing and identification purposes.

 

O

Out-of-Network: Healthcare providers or facilities that do not have a contract with a patient’s insurance plan, often resulting in higher out-of-pocket costs for the patient.

Out-of-Pocket Maximum: The maximum amount a patient must pay for covered healthcare services in a plan year, after which the insurance company covers 100% of costs.

 

P

Patient Responsibility: The portion of healthcare costs that a patient is responsible for paying, including deductibles, copayments, and coinsurance.

Preauthorization: The process of obtaining approval from an insurance company before a healthcare service is provided to ensure coverage.

Provider: A healthcare professional or facility that provides medical services, such as doctors, nurses, hospitals, and clinics.

 

R

Reimbursement: The payment made by an insurance company to a healthcare provider for services rendered.

Remittance Advice (RA): A document sent by an insurance payer to a healthcare provider detailing the payment and any adjustments made to the claim.

 

S

Superbill: A detailed receipt provided by a healthcare provider that includes a list of services rendered, along with the associated charges and codes, used for insurance claims.

 

T

Third-Party Payer: An entity (other than the patient or healthcare provider) that pays for healthcare services, such as an insurance company or government program.

 

U

Upcoding: The practice of using a higher-level code than is warranted for a medical service to increase reimbursement.

 

V

Verification of Benefits (VOB): The process of confirming a patient’s insurance coverage and benefits before providing services.

 

W

Write-Off: The amount of a bill that a healthcare provider deducts from a patient’s account, often due to contractual agreements with insurance companies.

 

X

X12: A set of standards for electronic data interchange (EDI) used in healthcare transactions, such as claims and remittance advice.

 

Z

Zero Payment: When an insurance payer denies a claim or determines that no payment is due for a submitted servic