Accounts Receivable (A/R)
- The total amount owed to a practice for services already rendered but not yet paid, whether by insurance payers or patients.
Adjudication
- The process by which a payer reviews a claim and determines how much, if anything, will be paid.
Adjustment
- A change to the billed amount, often reflecting a contracted rate difference between the billed charge and the allowed amount.
Allowed Amount
- The maximum amount a payer will reimburse for a given service under a specific plan or contract.
Appeal
- A formal request asking a payer to reconsider a denied or underpaid claim, typically with supporting documentation.
Charge Entry
- The process of recording billable services and associated codes into a billing system prior to claim submission.
Claim Scrubbing
- An automated or manual review of a claim prior to submission to catch errors that could cause a rejection or denial.
Clean Claim
- A claim submitted with all required information, free of errors, that can be processed without additional documentation.
Clearinghouse
- A third-party service that transmits claims electronically between providers and payers, often performing basic error checks along the way.
CPT Code
- Current Procedural Terminology code: a standardized code set used to describe medical, surgical, and diagnostic services.
Credentialing
- The process of verifying a provider's qualifications and enrolling them with insurance payers so they can bill for services.
Days in A/R
- A metric measuring the average number of days it takes a practice to collect payment after a service is billed.
Denial
- A payer's refusal to pay a claim, in whole or in part, typically accompanied by a reason code.
Eligibility Verification
- Confirming a patient's active insurance coverage and benefit details prior to a scheduled service.
EOB (Explanation of Benefits)
- A statement from a payer explaining how a claim was processed, including amounts billed, allowed, paid, and owed by the patient.
ERA (Electronic Remittance Advice)
- The electronic version of an EOB, used to automate payment posting.
HCPCS Code
- Healthcare Common Procedure Coding System code: used alongside CPT codes, often for supplies, equipment, and certain services.
ICD-10 Code
- International Classification of Diseases, 10th Revision: the code set used to represent diagnoses.
Modifier
- A two-character code appended to a CPT or HCPCS code to provide additional detail about a service without changing its definition.
Patient Responsibility
- The portion of a bill owed directly by the patient after insurance has processed the claim, such as copays, coinsurance, or deductibles.
Payment Posting
- Recording payments and adjustments received from payers and patients into the billing system.
Prior Authorization
- Approval required from a payer before certain services are performed, confirming the service will be considered for coverage.
Revenue Cycle Management (RCM)
- The full financial process of a healthcare encounter, from patient scheduling and registration through final payment collection.
Timely Filing
- The payer-defined deadline by which a claim must be submitted in order to be considered for payment.
Write-Off
- A balance removed from a patient's or payer's account, typically because it is uncollectible or falls outside a contracted rate.
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