NCMOA key terms

The process of booking, rescheduling, and tracking patient visits so that provider time, rooms, and equipment are used efficiently while patient needs are met.

A method for proactively contacting patients when a follow-up visit, preventive screening, or chronic care check is due, often generated from the practice management system.

Written rules stating how much notice a patient must give to cancel and what charges or consequences follow a missed visit, disclosed before the appointment.

A document or electronic screen listing the services, procedures, and diagnoses for a visit so the clinician can document what was performed and support billing.

The complete, chronological collection of a patient's clinical information, including history, findings, orders, results, and communications, maintained as a legal business record.

A documentation format that organizes notes around a numbered list of patient problems, with progress notes written for each problem in a consistent sequence.

A progress note structured into Subjective (patient-reported), Objective (observed or measured), Assessment (clinical impression), and Plan (next steps) sections.

A system-generated log recording who accessed or changed an electronic record, when, and from where, used to detect unauthorized use and support compliance reviews.

A policy specifying how long each type of record must be kept before lawful destruction, based on state law, payer contracts, and federal requirements.

Converting dictated clinical audio into written documents such as reports and letters, with accuracy checks for terminology, numbers, and patient identifiers.

A clinician speaking notes aloud for later transcription or speech-recognition software, following conventions that separate sections and clearly mark numbers and names.

Individually identifiable health information created, received, or maintained by a covered entity or business associate, in any form, that relates to care, payment, or health status.

Federal regulation governing how covered entities may use and disclose protected health information and outlining patient rights over their records.

The principle that a use or disclosure of protected health information should be limited to the least amount reasonably needed to accomplish the intended purpose.

A written statement given to patients explaining how their health information may be used and disclosed and describing their rights and the practice's duties.

A contract requiring a vendor that handles protected health information on a covered entity's behalf to safeguard it and meet specified privacy and security obligations.

Federal regulation requiring administrative, physical, and technical safeguards to protect electronic protected health information from unauthorized access, alteration, or loss.

A patient's signed permission allowing a specific use or disclosure of protected health information for purposes not otherwise permitted, such as marketing or research.

The controlled process of disclosing records to a requesting party after verifying the patient's consent and the requester's legal right to receive them.

Federal law that created national standards for protecting health information and for electronic healthcare transactions, and set rules on portability and fraud enforcement.

Mandated electronic formats and data content for common administrative exchanges such as claims, eligibility inquiries, remittance advice, and referral authorizations.

Computer-to-computer exchange of standardized business documents, such as claims and payment remittances, between providers and payers without manual reentry.

Checking with a payer whether a patient is enrolled, what coverage is active on the date of service, and what cost sharing and limits apply.

Confirming the specific services a plan covers, including prior authorization needs, visit limits, and exclusions, before care is delivered or billed.

Rules determining which of a patient's multiple insurance plans pays first and how the secondary plan pays after the primary plan's payment.

Advance approval from a payer required before certain services, drugs, or procedures are performed, confirming medical necessity and coverage.

A request directing a patient to another provider for evaluation or treatment, which may also be a payer requirement that must be documented before the visit.

Deliberately organizing a patient's care among providers, settings, and resources so that information is shared and handoffs do not cause gaps or duplication.

A communication method in which the sender confirms the receiver heard and understood the message, using read-back or acknowledgment, to prevent errors.

Documentation of a phone contact with a patient, caregiver, or payer, recording date, participants, reason, advice given, and any follow-up required.

Qualified language assistance, including spoken and sign language, provided so patients with limited English proficiency can understand and participate in their care.

A standardized code set describing medical services and procedures, maintained by the American Medical Association and used mainly for outpatient and physician billing.

A code set with Level I (CPT) and Level II codes for supplies, drugs, and equipment not described by CPT, used for Medicare and many commercial claims.

The diagnostic coding system used to report the patient's conditions and the reason for each service, supporting medical necessity on claims.

A CPT code category for visits involving history, examination, and medical decision making, selected by documented complexity or time.

A two-character code appended to a procedure code to show that a service was altered by circumstance, such as a distinct site or a reduced service.

The determination that a service is reasonable and required to diagnose or treat a condition according to accepted standards, which payers review before paying.

A formatted request for payment submitted to an insurer that identifies the patient, provider, diagnoses, services, and charges for a date of service.

A claim containing all required data elements and free of errors, so the payer can process it without requesting additional information.

A payer statement to the patient showing services billed, amounts allowed, paid, and left as patient responsibility, along with any denial reasons.

An electronic or paper notice from a payer accompanying payment that lists claims processed, amounts paid or denied, and adjustment reason codes.

A payer's refusal to pay all or part of a claim, which must be categorized, corrected if possible, and either resubmitted or appealed within deadlines.

A formal request that a payer reconsider a denial or underpayment, supported by records and policy citations and filed within the plan's time limit.

A fixed dollar amount the patient pays at the time of an eligible service, separate from deductible and coinsurance amounts.

The patient's share of an allowed charge expressed as a percentage, applied after the deductible is met, with the plan paying the remainder.

The amount a patient must pay out of pocket for covered services each benefit period before the plan begins paying its share.

A written notice given to a Medicare patient before a service the provider expects Medicare to deny as not medically necessary, shifting financial responsibility if signed.

Intentional deception for gain, unnecessary spending, and practices that misuse resources; staff must recognize and report these patterns under compliance programs.

A federal law imposing liability on those who knowingly submit false or fraudulent claims to government payers, with protections for whistleblowers who report them.

An organization's structured effort to prevent and detect violations of law and payer rules, including written policies, training, monitoring, and a reporting mechanism.

Software that handles registration, scheduling, insurance data, charge entry, and claim tracking, often linked to the electronic health record.

A digital record of a patient's health information shared across care settings, supporting documentation, orders, results, and clinical decision support.

A patient-requestable report listing certain disclosures of their protected health information for the prior six years, excluding those made for treatment, payment, or operations.