CBCS key terms

The process of confirming with a payer, before services are rendered, that a patient is covered, the coverage is active on the date of service, and what benefits and patient cost-sharing apply. It helps prevent denials.

A payer's requirement that a provider obtain approval before delivering certain services, drugs, or equipment. The payer reviews medical necessity and issues an approval or denial, often with a reference number.

A written or electronic order from a primary care provider or payer directing a patient to a specialist or for specific services. Some plans require referrals before specialist care is covered.

The rules that determine which health plan pays first when a patient is covered by more than one plan. The primary plan pays first; the secondary plan considers the remaining balance.

A provider who has a contract with a health plan to furnish services at agreed rates. Patients usually pay less when they see in-network providers; out-of-network care may cost more or be denied.

A unique identifier a payer assigns when it approves a service through prior authorization or precertification. It is entered on the claim to show the service was approved.

The standardized code set used in the United States to report diagnoses and reasons for visits on claims. Codes describe conditions, symptoms, and external causes and support medical necessity.

Current Procedural Terminology, a code set maintained by the American Medical Association that describes medical services and procedures. CPT codes are used on claims to report what the provider did.

A national code set maintained by CMS for products, supplies, and services not represented by CPT codes, such as drugs, durable medical equipment, and ambulance services. Codes begin with a letter.

A two-character code added to a procedure code to report a specific circumstance, such as which side of the body was treated or that a service was performed separately. Modifiers affect payment.

Evaluation and Management codes report visits in which a provider assesses and manages a patient's condition, such as office visits and hospital visits. The level is selected using documented history, examination, and medical decision making.

A two-digit code on a claim identifying where a service was furnished, such as a physician office, hospital outpatient department, or patient home. Payment rates and coverage can vary by setting.

The part of a claim that links each reported procedure to the specific diagnosis code that justifies it. Correct pointers help payers see that the service was medically necessary.

The determination that a service, test, or treatment is reasonable and required to diagnose or treat a patient's condition according to accepted standards. Payers review medical necessity when deciding whether to pay.

The standard paper claim form used to bill professional services to Medicare and most other payers. It captures patient, insured, provider, diagnosis, procedure, and charge information.

The standard claim form used by hospitals and other institutional providers to bill facility services. Also called the CMS-1450, it reports revenue codes, condition codes, and other facility-specific data.

A claim that contains all required information, is free of errors, and meets the payer's formatting and coding rules so it can be processed without manual intervention or requests for more information.

The maximum amount a payer will recognize for a covered service under its contract or fee schedule. The payer pays part of the allowed amount and the patient may owe the remainder.

The amount a patient must pay out of pocket for covered services before the health plan begins paying its share, usually within a defined benefit period. Deductibles vary by plan.

The patient's share of the cost of a covered service, expressed as a percentage of the allowed amount after the deductible is met. For example, a 20% coinsurance means the patient pays 20%.

A fixed dollar amount a patient pays at the time of a covered service, such as $25 for an office visit. Copays are set by the health plan and do not usually count toward the deductible.

The deadline set by a payer or contract for submitting a claim or appeal. Claims received after the limit are generally denied, so tracking filing dates is essential.

A document from a health plan explaining how a claim was processed, including billed charges, allowed amounts, payments, patient responsibility, and reasons for any denial. It is not a bill.

An electronic file sent by a payer that reports claim adjudication results, including payments, adjustments, and denial reasons. It supports automated posting of payments and reconciliation of accounts.

A payer's decision not to pay a claim, in whole or in part, because of reasons such as missing information, non-coverage, timely filing, or lack of authorization. Denials must be worked promptly.

A formal request that a payer reconsider a denied or underpaid claim. Appeals usually must be filed within a deadline and should include supporting documentation and a clear rationale.

The total amount of money owed to a practice for services already provided but not yet paid. Monitoring A/R shows how much revenue is outstanding and how quickly it is being collected.

A report that groups unpaid claims and patient balances by how long they have been outstanding, such as 0-30, 31-60, or 61-90 days. It helps prioritize collection efforts.

The process of recording payments and adjustments to patient accounts, matching each payment to the correct claim and service line. Accurate posting keeps balances and reports reliable.

The difference between a provider's billed charge and the amount the payer's contract allows. It is written off as part of the agreement and is not billed to the patient.

An amount removed from a patient's account balance because it will not be collected, such as a contractual adjustment, a small balance, or uncollectible debt. Write-offs must follow policy.

A patient or payer balance that is considered uncollectible after reasonable collection efforts. It may be written off or turned over to a collection agency according to practice policy.

The ongoing process of identifying, categorizing, appealing, and preventing claim denials. It includes tracking denial reasons and correcting root causes to improve future reimbursement.

A form or electronic template used by clinicians to record diagnoses, procedures, and services provided during an encounter. It becomes the source document for charge entry and claim creation.

The Health Insurance Portability and Accountability Act, a federal law that protects health insurance coverage and sets national standards for the privacy and security of health information.

Individually identifiable health information that is created, received, or maintained by a covered entity or business associate. HIPAA limits how PHI may be used, disclosed, and safeguarded.

A HIPAA principle requiring covered entities to limit the use, disclosure, or request of protected health information to the amount reasonably needed to accomplish the intended purpose.

Intentional deception or misrepresentation that an individual knows to be false and that may result in unauthorized payment or benefit. Examples include billing for services never provided.

Practices that directly or indirectly result in unnecessary costs to the health care system, such as overcharging or improper coding, without the intent required for fraud. Abuse can lead to sanctions and recoupment.

A federal law that prohibits knowingly offering, paying, soliciting, or receiving anything of value to induce referrals for items or services covered by federal health care programs. Violations carry criminal penalties.