Healthcare Payer & Providers Glossary

Accounts receivable (AR) in healthcare are reimbursements or invoices owed to a hospital, medical practice, or other healthcare organizations by patients or healthcare plans.

The Advance Beneficiary Notice of Noncoverage (ABN) is a form (CMS-R-131) that helps Medicare Fee-for-Service (FFS) patients make informed decisions. ABN informs them about items and services that may not be covered in specific situations.

The allowable charge is the highest amount a health insurance payer will reimburse for a specific medical procedure.

An Alternative Payment Model (APM) is a value-based reimbursement approach designed to promote high-quality, cost-efficient care by offering incentive payments. APMs apply to specific clinical conditions, patient populations, or care episodes, shifting away from traditional fee-for-service models by using bundled payments and care coordination methods.

Ambulatory Payment Classification (APC) is the method the government uses to pay facilities for outpatient services through the Medicare program.

The base payment rate in healthcare is the specified amount set by payers for reimbursing providers for the services rendered that can be changed for different patient conditions, geographic locations, or facility types.

A benefit period is when an insurance policyholder or their dependents are eligible to file claims and receive payments for covered events.

The Charge Description Master (CDM) is a vital resource in healthcare, containing a comprehensive list of services and supplies along with their corresponding charges.

A charge status indicator is a code used in healthcare to uniquely identify a charge's status (pending, denied, or billed).

Department code in the healthcare industry refers to the unique identifier associated with a specific department, which enables accurate revenue tracking and allocation.

Evaluation and Management (E/M) codes are the set of codes used for medical billing. They represent particular services provided by physicians and are reimbursed based on the complexity of the services offered.

Healthcare fraud can be committed by patients, providers, or payers who intentionally deceive the healthcare system, implicating false claims, actions, or documents to obtain financial gain or unauthorized benefits.

The global payment method involves a lump sum amount paid to physician groups per patient for a specific period, regardless of the actual care provided.

Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that offers provisions for data privacy and security to safeguard sensitive patient medical information and prevent it from being disclosed without the patient's consent or information.

The ICD-10 Coordination and Maintenance Committee (C&M) is a federal interdepartmental group that maintains and updates ICD-10-CM and ICD-10-PCS code sets.

Limitation refers to the lack of capacity or restrictions imposed that may hinder the performance of revenue cycle management (RCM) processes in healthcare.

Medicaid is a collaborative federal and state program that covers medical costs for people with limited income and resources.

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Learn about denials in medical billing, including denial codes, effective management, and prevention techniques.

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Explore how medical coding automation enhances accuracy, reduces costs, and streamlines RCM processes for healthcare providers.

Medical coding software changes how coders work. Learn everything you need to know about medical coding software here.

The Beveridge Model of Health Care is a system in which the government provides healthcare to all citizens through income tax payments.

An open enrollment period refers to the window of time that occurs once a year when you can sign up for health insurance, modify your current plan, or cancel your plan.

Patient registration is the process of enrolling a patient's name and identity into the hospital records to keep track of services provided to each patient.

A physician query is an official request made by a medical coder for additional information from the provider.

Healthcare reimbursements incorporate the process of compensating providers or physicians for the care provided by insurance payers.

Explore how revenue cycle flowchart helps streamline processes, improves collaboration, and clarifies interdependencies.

Looking for detailed information on healthcare RCM? This comprehensive guide has everything you need to know about revenue cycle management.

Learn how automation in RCM can improve efficiency and productivity for healthcare providers in this guide.

Learn everything about outsourcing RCM in this guide. Healthcare providers get answers to all their questions.

Enacted in 1935, the Social Security Act provides benefits for old-age retirees, dependent mothers and children, the jobless, victims of work-related accidents, blind people, and people who have physical disabilities.

A third-party payer is an entity, such as a private insurance company or a government-funded program like Medicaid or Medicare, that is responsible for reimbursing providers for care provided to patients.

Unbundling in healthcare refers to the process of separating and billing different healthcare service components that are bundled together.

The Veterans Health Administration (VHA) is the largest government agency that offers specialized care, primary care, and related social and medical support services to the U.S. veterans.

The waiting period in healthcare is the duration for which you have to wait before getting benefits, which begins from the date of policy commencement.