Electronic Remittance Advice sent by health insurance payers explaining how a claim was processed - detailing amounts paid, denied, adjusted, or transferred to the patient's responsibility.
HIPAA-compliant electronic document used by healthcare providers to submit medical claims to clearinghouses and insurance payers.
837P - professional claims
837I - institutional claims
837D - dental claims
An advance beneficiary notice of noncoverage (ABN) informs patients that Medicare is not expected to cover a treatment or service, and lists the estimated cost. The patient then chooses to either accept financial responsibility and sign the form, or decline — in which case the treatment or service is not performed and the provider is notified.
Coordination of Benefits - The process insurance companies use to decide which health plan pays first (primary payer) and which pays second (secondary payer) when a patient is covered by more than 1 health insurance policy.
Current Procedural Terminology - a 5-digit numerical code created by the American Medical Association and used by medical providers to report medical, surgical, and diagnostic services.
Durable Medical Equipment
Date of Service
Electronic Data Interchange - the automated, computer-to-computer transfer of documents such as insurance claims, eligibility, and benefit checks.
Healthcare Common Procedure Coding System- a standardized collection of codes used by medical providers in billing and processing health insurance claims.
International Classification of Diseases, 10th Revision. A standardized, alphanumeric coding system created by the World Health Organization, used to classify and report diagnoses, symptoms, and injuries.
Medicare Secondary Payer - a federal rule where Medicare pays for a medical claim after another insurance plan pays first. Common situations where this applies include:
(This is not an exhaustive list.)
* The patient is 65 or older, is working, and has health insurance coverage through that employer.
* The patient is 65 or older and has a spouse who is still working at a company with 20 or more workers.
* The patient is under 65, has a disability, and is covered under a large job health plan.
* The patient has end-stage renal disease (ESRD) and is in a specific waiting period.
National Provider Identifier - a unique 10-digit identification number issued to U.S. Healthcare providers and organizations by the Centers for Medicare and Medicaid Services (CMS). There are 2 types. A type 1 NPI number is for a single healthcare provider. A type 2 NPI number is an organizational number for clinics, group practices, hospitals, and pharmacies.
Prior Authorization - approval that your health provider must obtain from your health insurance company before rendering certain services, treatments, or medications. The authorization is not a guarantee of payment, only that it meets their medical necessity guidelines.
Place of Service - Standardized two-digit numeric code used on a medical claim to identify the exact physical or virtual setting where a medical service or procedure was performed.
Patient Responsibility
Revenue Cycle Management
Tax Identification Number - a unique 9-digit code used to identify the specific medical practice, facility, or individual provider who receives financial reimbursement and reports income.