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.

Discover what administrative denials are, their causes, and how they differ from medical necessity denials. Learn through examples like coding errors and incomplete claims.

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.

Understand bundled payments, a value-based reimbursement model for efficient healthcare. Explore examples in joint replacement, cardiac care, and chronic condition management.

Case mix measures the types and complexity of patients treated in a healthcare facility, determining the required resources and influencing reimbursement rates.

A case-mix group (CMG) is a classification system used to group patients with similar characteristics and conditions together.

Discover how case-rate methodology works, its benefits, and examples. Learn how this fixed-payment model simplifies billing and promotes cost efficiency in healthcare.

Discover how charge descriptions enhance billing accuracy and transparency. Learn their importance in claims processing and see examples in emergency care and dental cleaning.

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).

A clinical denial occurs when an insurance payer rejects a healthcare claim because of a mismatch between the clinical documentation and the services billed.

Understand clinical validation denial, its impact on claims, and how to avoid it. Explore examples and strategies for ensuring accurate and compliant documentation.

A coding compliance plan is a documented strategy that outlines procedures to ensure accurate and compliant medical coding practices within healthcare organizations.

Coding management refers to overseeing and optimizing the accurate assignment of medical codes to healthcare services and procedures.

Community rating is referred to as a healthcare pricing model in which insurance premiums are calculated based on the average cost of healthcare services.

Contractual allowance refers to the difference between the standard charges for healthcare services and the amount contractually agreed upon with payers or insurance companies.

Coordination of benefits (COB) is a process used by health insurance plans to determine the order in which multiple insurance plans will pay for a claim.

Explore cost reports in healthcare, their impact on reimbursements, and types like Medicare, skilled nursing, and clinic cost reports. Learn how they guide financial transparency.

Explore how cost-of-living adjustments (COLA) impact healthcare salaries, Social Security, and Medicare. Learn about its purpose, examples, and regulatory guidelines.

A covered condition in healthcare refers to the medical conditions that are eligible for reimbursement by the healthcare payers.

A covered service can be defined as a medical procedure, treatment, or healthcare service that qualifies for reimbursement under a patient's insurance plan or government program.

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

Discover the essentials of EOB in medical billing. Learn how it simplifies claims, ensures transparency, prevents errors, and supports compliance.

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.

Comprehensive medical billing guide. Learn all the essential tips needed handcrafted by medical billing experts.