Healthcare Payer & Providers Glossary

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.

Family coverage is typically a health insurance plan that covers an entire family unit, which includes the primary policyholder, their spouse or dependent children or legal wards.

The Federal Employees' Compensation Act (FECA) provides wage replacement, medical care, and other benefits for federal workers injured on the job. Learn how it works, what it covers, and how it differs from standard workers’ comp.

A fee schedule in healthcare is a list of set rates for medical services, determined by providers, insurers, or government programs. It ensures standard payments and transparency for both patients and healthcare providers.

A formulary is a list of approved prescription medications covered by a health insurance plan or healthcare system, guiding cost-effective and safe treatment. It helps control costs, improve care, and streamline medication management.

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.

A gatekeeper refers to a person, team, or technology solution that oversees the movement of billing, patient, and administrative information across critical control points, ensuring accuracy, compliance, and readiness before the data advances to the next phase of the revenue cycle.

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.

A guarantor is anyone, typically parents or legal guardians, who takes financial responsibility for the medical expenses of a patient.

Hard coding refers to the practice of automatically assigning procedure or diagnosis codes to medical services through the hospital’s Charge Description Master (CDM), rather than relying on manual coding by health information management (HIM) professionals. 

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.

A Local Coverage Determination (LCD) is a regional Medicare policy issued by a Medicare Administrative Contractor (MAC) that outlines the coverage criteria, billing guidelines, and documentation requirements for specific medical services, procedures, or supplies deemed reasonable and necessary within that contractor’s jurisdiction.

A Major Complication and Comorbidity (MCC) is essentially any serious secondary diagnosis that increases the complexity of a patient's condition. As a result, it also increases the resources required to treat it.

A Major Diagnostic Category (MDC) is a classification system used to group hospital patients according to their principal diagnosis or the body system involved. This system helps streamline hospital billing, resource allocation, and data analysis by aligning clinical conditions with standardized administrative categories.

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.

A medical billing clearinghouse improves claim processing speed and accuracy. Learn everything you need to know about a medical billing clearinghouse here.

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

Get an in-depth understanding on medical coding. Learn all the essential tips needed handcrafted by medical coding experts.

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

Outsourcing medical coding streamlines revenue cycle management, reduces costs, improves accuracy, and ensures compliance. Learn how outsourcing enhances overall efficiency.

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

A Medicare Severity Diagnosis‑Related Group (MS‑DRG) is a system that classifies hospital inpatient stays into categories based on diagnoses, procedures, and severity to determine Medicare reimbursement.

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.

A Participating Physician (PAR) is a healthcare provider who has entered into an agreement with an insurance company to accept the insurer’s approved amount as full payment for covered services. This essentially means PAR physicians agree to the reimbursement rates set by the insurer and typically handle claims submission directly.

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.

“Per Member Per Month”, or PMPM for short, is a common way of measuring costs, spending, and sometimes even profits in the healthcare industry. It refers to the average cost (or revenue) for a single member each month.

The principal diagnosis is the main condition, determined after clinical evaluation, that led to the patient's hospital admission, as defined by UHDDS guidelines.

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.

Remittance Advice (RA) is a detailed document issued by a health insurance company or third-party payer to a healthcare provider, explaining how submitted claims were processed. It outlines whether claims were paid in full, partially paid, or denied, and provides reasons for adjustments, denials, or rejections.

A revenue code is a numeric code that is used in medical billing. It indicates the type of service or department that provided care to a patient. It is also assigned on the UB-04 (CMS-1450) claim form and helps payers gain clarity about the services rendered and other associated details.

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