Reference
Medical Billing and Reimbursement Glossary
Plain-language definitions connected to deeper rule lessons and official-source research.
41 terms
- 270/271Eligibility Inquiry and Response
- HIPAA electronic transactions used to request and return health plan eligibility and benefit information. A response is not a payment guarantee.
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- 277CAHealth Care Claim Acknowledgment
- An acknowledgment that reports whether individual claims were accepted or rejected for further payer processing after initial transaction edits.
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- 835Health Care Claim Payment and Remittance Advice
- The standard electronic transaction that communicates claim payment, adjustments, reason codes, remark codes, and provider-level adjustments.
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- 837IInstitutional Health Care Claim
- The standard electronic claim format used by hospitals and other institutional providers.
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- 837PProfessional Health Care Claim
- The standard electronic claim format used by physicians, practitioners, and many suppliers for professional services.
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- ABNAdvance Beneficiary Notice of Noncoverage
- A specific Original Medicare notice used before furnishing certain items or services expected to deny, when the applicable notice rules require it.
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- Allowed amount
- The amount a payer recognizes for a covered service before applying payment, deductible, coinsurance, contract, or other adjustments.
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- Appeal
- A formal request to review a coverage or payment determination. Rights, deadlines, levels, and destinations depend on the payer and notice.
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- CARCClaim Adjustment Reason Code
- A standard code that gives the general reason for a claim or service-line financial adjustment on a remittance.
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- Clean claim
- A claim that can be processed without external prepayment investigation or development and that meets applicable submission requirements.
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- CMS-1450Institutional Paper Claim Form
- The standard institutional paper claim form, also called UB-04, used when an applicable paper-claim exception permits it.
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- CMS-1500Professional Paper Claim Form
- The standard professional paper claim form used when an applicable paper-claim exception permits it.
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- COBCoordination of Benefits
- The process used to determine payer order and transmit prior-payer adjudication when a person has more than one health plan.
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- Corrected claim
- A claim submitted through the payer's required replacement or correction process to change data on a previously received claim.
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- CPTCurrent Procedural Terminology
- The AMA-maintained code set used for many physician and outpatient services. Current licensed code content and guidance should be used.
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- DMEPOSDurable Medical Equipment, Prosthetics, Orthotics, and Supplies
- A Medicare payment and supplier category covering equipment, prosthetics, orthotics, supplies, and related items under applicable benefit and policy rules.
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- ERAElectronic Remittance Advice
- The electronic 835 explanation of payer adjudication, payment, adjustments, CARCs, RARCs, and provider-level balance activity.
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- Group codeClaim Adjustment Group Code
- A remittance code category such as CO or PR that helps assign the type of financial responsibility for an adjustment.
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- HCPCS Level IIHealthcare Common Procedure Coding System Level II
- The CMS-maintained alphanumeric code set used primarily for supplies, drugs, equipment, and services not included in CPT.
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- ICD-10-CMInternational Classification of Diseases, Tenth Revision, Clinical Modification
- The diagnosis code set used for reporting diseases, conditions, injuries, symptoms, and reasons for encounters.
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- ICD-10-PCSInternational Classification of Diseases, Tenth Revision, Procedure Coding System
- The procedure code set used for inpatient hospital procedures in the United States.
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- LCDLocal Coverage Determination
- A Medicare Administrative Contractor determination describing when a service is considered reasonable and necessary within its jurisdiction.
- MACMedicare Administrative Contractor
- A contractor that processes and administers defined Original Medicare claims and related functions for a jurisdiction.
- Medical necessity
- The service-specific requirement that an item or service be reasonable and necessary under applicable benefit, coverage, and payment rules and supported by the record.
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- Modifier
- A code appended to a procedure or service code to communicate a documented circumstance without changing the underlying code definition.
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- MSPMedicare Secondary Payer
- The federal rules that determine when another plan or coverage pays before Medicare.
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- MUEMedically Unlikely Edit
- A Medicare unit-of-service edit applied to a code, provider, beneficiary, and date under a specified adjudication method.
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- NCCINational Correct Coding Initiative
- CMS coding-edit programs that include procedure-to-procedure, medically unlikely, and add-on-code edits.
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- NCDNational Coverage Determination
- A CMS national determination describing whether and under what conditions Medicare covers a specific item or service.
- NPINational Provider Identifier
- A 10-digit standard identifier for covered health care providers. It does not by itself grant billing privileges.
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- PECOSProvider Enrollment, Chain, and Ownership System
- The CMS system used to manage Medicare provider and supplier enrollment information.
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- Place of service
- The two-digit code on professional claims that identifies the setting where the service was furnished.
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- Prior authorization
- A payer decision made before a service under plan rules; scope may include service, provider, setting, units, and dates.
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- RARCRemittance Advice Remark Code
- A standard remark code that adds detail to a claim adjustment reason or communicates other remittance information.
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- Rejection
- A claim or batch failure before final adjudication, usually requiring data correction and resubmission rather than appeal.
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- Reopening
- A process for revising an eligible Medicare determination, often for minor errors or omissions, under administrative-finality rules.
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- Remittance advice
- The payer explanation of claim adjudication, including allowed amounts, payment, adjustments, and reason or remark codes.
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- Revenue code
- An institutional claim code that classifies a department, accommodation, or service category; it may require related procedure information.
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- Taxonomy code
- A provider classification code describing type, classification, or specialization; payer enrollment and claim use must remain aligned.
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- Timely filing
- The payer deadline for receiving a claim or other request. Original Medicare generally uses a one-calendar-year claim filing limit.
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- Type of bill
- An institutional claim code that communicates facility type, care classification, and bill sequence or frequency.
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