NHA CBCS key terms

A claim submitted with all required fields completed correctly, valid codes, and no missing or contradictory information, so a payer can process it without manual intervention or a request for additional data.

Software that checks claims against payer rules and coding edits before submission, flagging missing fields, invalid code combinations, and formatting problems so errors are corrected before the claim leaves the practice.

A payer's refusal to process a claim because of a data or formatting error, such as a missing identifier or invalid code. The claim is not adjudicated and can be corrected and resubmitted.

A payer's decision, after adjudication, not to pay a claim or service line. Denials cite reasons such as non-coverage, missing authorization, or medical necessity and require appeal or correction rather than simple resubmission.

Payer-agnostic code pair rules that identify services not separately reportable together, including column one and column two pairs and mutually exclusive procedures. Correct modifier use may allow payment for both services.

A two-character code appended to a procedure code to report a specific circumstance, such as a distinct service, laterality, or reduced service, without changing the underlying procedure's meaning.

A two-digit code on the claim identifying where a service was furnished, such as a physician office or outpatient hospital. The code affects payment rates and which facility or professional rules apply.

A procedure code describing a professional encounter such as an office visit, selected by documented history, examination, and medical decision making or time. Level selection must match the documentation in the record.

The determination that a service is reasonable and required to diagnose or treat a condition according to accepted standards. Payers deny claims lacking supporting documentation of need.

A written notice given to a Medicare beneficiary before a service the provider expects Medicare to deny as not medically necessary, allowing the patient to accept financial responsibility if the denial occurs.

Rules determining which of a patient's multiple insurance plans pays first and how much each plan pays. The primary plan pays first; the secondary plan considers the remaining balance.

The insurance plan that processes and pays a claim first when a patient has more than one coverage. Its payment and adjustments are reported to the secondary plan for consideration.

The insurance plan that considers a claim after the primary payer has adjudicated it, paying remaining covered amounts according to its own rules and the primary plan's allowed amount.

The maximum period, set by payer contract or regulation, within which a claim must be received for payment. Claims filed after the deadline are typically denied unless a valid exception applies.

A formal request asking a payer to reconsider a denial or payment decision, supported by documentation and citing the reason the original determination was incorrect. Appeals follow payer-specific levels and deadlines.

A statement from a payer to the patient and provider showing charges, allowed amounts, payments, adjustments, and patient responsibility for processed claims. It is not a bill.

An electronic or paper document from a payer to a provider listing claims processed in a payment cycle, with paid, denied, and adjusted amounts plus remark codes explaining each decision.

The electronic version of a remittance advice, delivered in a standard format so payment and adjustment data can be posted automatically to the practice management system without manual keying.

The computer-to-computer exchange of standard healthcare transactions, such as claims, eligibility inquiries, and remittances, between providers and payers using nationally recognized formats.

An intermediary that receives claims from providers, checks them against payer requirements, and forwards them to the correct payer, returning reports of accepted and rejected claims.

The maximum amount a payer will recognize for a covered service under its fee schedule or contract. Payment plus patient responsibility generally cannot exceed this figure.

The difference between a provider's billed charge and the payer's allowed amount, written off per the participating provider agreement. It cannot be billed to the patient.

The portion of a covered service's cost the patient owes, including copayment, coinsurance, deductible, and non-covered amounts. It is calculated after the payer adjudicates the claim.

A fixed dollar amount the patient pays for a covered service, often collected at the time of visit. It is separate from coinsurance and does not vary with the cost of the service.

The patient's share of a covered service's cost expressed as a percentage of the allowed amount, after any deductible is applied. The payer covers the remaining percentage.

The amount a patient must pay out of pocket for covered services before the health plan begins paying its share, typically reset each benefit year.

The process of confirming, before services are rendered, that a patient's coverage is active and what benefits, limits, and cost-sharing apply, reducing later denials for no coverage.

Payer approval obtained before certain services are performed, confirming the service meets coverage criteria. Performing the service without approval often results in denial.

A document or electronic form used at the point of care to capture diagnoses, procedures, and charges for an encounter, which then becomes the source for claim creation.

The process of recording every service and supply provided during an encounter so it can be billed. Missed or late capture causes lost revenue and inaccurate claims.

The billing step of entering captured charges and their codes into the practice management system, linking them to the correct patient, provider, and encounter before claim generation.

A list of established prices for services a practice bills, which may be based on payer contracts, relative value units, or practice policy. It determines billed charges before adjustments.

A statement issued to a patient or responsible party itemizing services, charges, payments, and amounts now due, used to request payment for balances the payer did not cover.

A periodic bill sent to a patient summarizing account activity, including new charges, insurance payments, and the current balance due, with payment instructions and due date.

Recording payer and patient payments against the correct claims and service lines in the billing system, along with adjustments and denials, so account balances reflect reality.

The direct deposit of payer payments into a provider's bank account, usually paired with an electronic remittance advice that identifies which claims the deposit covers.

A report grouping outstanding patient and payer balances by how long they have been unpaid, such as 0-30 or 31-60 days, to prioritize collection follow-up.

The total money owed to a practice for services already billed but not yet paid. Monitoring its total and age distribution shows how well revenue cycle work is performing.

Removing an amount from a patient or payer balance because it is uncollectible or contractually not billable, with the reason documented so the adjustment can be audited.

Collecting known patient amounts, such as copayments or prior balances, at the time of the visit rather than billing later, which reduces statement costs and bad debt.