Every term on this site, in plain words. Read the way a payer reads it.

837P to credentialing.

837P

The standard electronic format for a professional claim, the kind a practice sends for office and clinic services. Hospitals and facilities send the institutional version, the 837I. Dental claims have their own, the 837D.

Appeal

A written request that a payer reconsider a claim it denied or underpaid. An appeal fits when the claim was right and the payer was wrong. When the fault is on the claim itself, the fix is a corrected claim instead. Each payer sets its own appeal levels and deadlines.

Business associate agreement (BAA)

The contract HIPAA requires before an outside firm handles PHI for a practice. It says what the firm may do with the information and how it must protect it. We sign one with the practice before any patient data changes hands. The free review needs none, because it uses no patient data.

CAQH

CAQH ProView is the shared profile most commercial payers read instead of sending a questionnaire of their own. It holds a provider's license, training, work history, malpractice cover and practice locations. The provider authorizes each plan to view it, and must re-attest it on a set cycle.^A

Clearinghouse

The company that carries electronic claims from a practice to its payers. It checks each claim for format errors before it goes, and brings back the payers' acknowledgments, rejections and remittances.

Closed panel

A payer's notice that it is not adding providers of your type where you practice. It says nothing about the quality of the file. Payers revisit it, panels reopen without warning, and a network adequacy gap or a group contract can still open a door.^B

Corrected claim

A claim sent again to replace one that went out wrong: a code, a modifier, a patient detail. It is marked as a replacement, so the payer reads it against the original instead of rejecting it as a duplicate.

CPT

Current Procedural Terminology, the American Medical Association's five-digit codes for procedures and services. The code names what was done. The diagnosis code says why. Hyperhidrosis treatment, for example, bills under CPT 64650 for the underarms and 64653 for other areas.^C

Credentialing

The payer checking a provider's license, education, board status, malpractice history and sanctions before it will admit that provider. Credentialing is a check, and passing it does not let anyone bill. Enrollment and an effective date come after it. Why “credentialed” is not “billable”.

Denial to HSA.

Denial

A payer's refusal to pay a claim or a line on it, with a reason code that says why. Some denials are fixed with a corrected claim, some with an appeal, and some only by fixing the enrollment behind them. In one poll of medical groups, 54% said credentialing-related denials were rising.^D

DMEPOS

Durable medical equipment, prosthetics, orthotics and supplies: Medicare's category for equipment a patient takes home. A practice that supplies it needs its own Medicare enrollment as a DMEPOS supplier. The plainest case is a dentist fitting an oral appliance for sleep apnea, which bills the medical plan under HCPCS E0486.^E

Effective date

The date a payer starts paying a provider's claims. Nothing billed for service before it is guaranteed payment. Every application we file is tracked to one. How long that takes depends on the payer: months for commercial plans, usually less for Medicare, and a state-by-state answer for Medicaid.^F

Eligibility and benefits

The check made before a visit: is the patient's coverage active, what does the plan cover for this service, what will the patient owe, and does the payer want approval first. A claim built on a stale eligibility answer is a claim built to be denied.

Enrollment

Payer enrollment is the payer registering a provider, or the practice itself, so claims pay in-network. It follows credentialing and ends in an effective date. Each payer takes its own application for each provider. How we run enrollment.

EOB

Explanation of benefits. The plan's statement of what was billed, what it allowed, what it paid and what the patient owes. Patients receive one, and it is not a bill. The practice's version arrives as a remittance, most often an ERA.

ERA

Electronic remittance advice, the file a payer sends with its payment, known in the trade as an 835. It says what the payer paid on each claim line and gives a reason code for anything it did not. We post every line against its claim, so a short payment shows up against the claim it belongs to.

Evaluation and management (E/M)

The CPT codes for office visits and consultations. The level billed rests on the medical decision-making or the time the visit took, and the note has to support it.

Fee schedule

The amount a payer allows for each code. Medicare publishes its own. A commercial plan's sits in the practice's contract. Comparing every payment line against it is how an underpayment is found.

FSA

Flexible spending account. Pre-tax money an employer plan sets aside for qualified medical expenses. The same qualified-expense test as an HSA applies.

Group contract

An agreement between a payer and the practice as an organization, apart from any one provider. With a group contract in place, some payers add new providers under it even when the panel is closed to individual applications. It is often the faster door.

HCPCS

The Healthcare Common Procedure Coding System. Its second level covers what CPT does not: equipment, supplies, drugs and some services, each coded with a letter and four digits. The sleep-apnea oral appliance is E0486.^E

HSA

Health savings account, paired with a high-deductible health plan. The money pays for qualified medical expenses, the test in section 213(d) of the tax code: care that diagnoses, treats or prevents a condition. A letter of medical necessity is how a purchase gets tied to a diagnosed condition.^G

ICD-10 to modifier.

ICD-10

The diagnosis codes on a claim, from the ICD-10-CM code set. Where CPT names what was done, the diagnosis code says why. A covered service billed against the wrong diagnosis reads to the payer as a service it does not cover.

In-network and out-of-network

In-network means the payer has enrolled the provider and pays at the contracted rate. Out-of-network means it has not, and the claim pays less, or nothing, depending on the plan. A provider can be fully enrolled with Medicare and still be out-of-network with every commercial plan nearby.

Incident-to

A Medicare rule that lets some visits by a clinician who is not yet enrolled bill under a supervising physician who is. The physician supervises directly, on site, and the visit follows a plan of care that physician already set. It is a bridge for supervised work, never a stand-in for enrollment, and commercial plans set their own limits on it.^H

Letter of medical necessity

A clinician's letter that ties a service or purchase to a diagnosed condition. For HSA and FSA spending, it is what shows the expense is qualified. Some payers ask for one too, when a service looks elective until the diagnosis is on paper.^G

Local coverage determination (LCD)

A Medicare contractor's written rule on when a service is covered in its region: which diagnoses, which documentation, which codes. The sleep-apnea oral appliance, for one, is governed by LCD L33611.^E

Medicare Advantage

Medicare benefits delivered by private insurers, each with a network of its own held to CMS network adequacy standards. Enrollment in traditional Medicare does not put a clinician in any of them. Each plan takes its own application.^B

Modifier

Two characters added to a CPT or HCPCS code to tell the payer something about how the service was done: a separate procedure on the same day, one side of the body, a visit by telehealth. A missing or wrong modifier is among the plainest reasons a correct service goes unpaid.

Network adequacy to prior authorization.

Network adequacy

The standards a plan is held to for having enough providers of each type within reach of its members. States set their own in statute, and CMS sets them for Medicare Advantage and Marketplace plans. A gap in the plan's own network is the strongest case for admission to a closed panel.^B

NPI

National Provider Identifier, the ten-digit number every provider bills under. Each clinician holds an individual NPI. A group practice has one of its own as an organization. Both live in NPPES.^I

NPPES

The National Plan and Provider Enumeration System, the national register of NPIs that CMS keeps and publishes. The name, address and specialty there have to match every application that follows. An old address in NPPES gets carried into each one, so we correct it first.^I

Panel

A payer's network of providers for a specialty in an area. Getting on the panel means the payer has accepted the provider. A panel can be open, or closed to new applications.

Payment posting

Recording each payment line from an ERA or EOB against the claim it belongs to. Done line by line, it is where a denial, a short payment or a patient balance first becomes visible. Done in lump sums, it hides all three.

PECOS

Provider Enrollment, Chain and Ownership System, Medicare's online enrollment system. The practice enrolls as an organization, each clinician enrolls as an individual, and then each clinician reassigns Medicare payments to the practice. Filed out of that order, the pieces have nothing to attach to. Medicare's order of operations.

Percent of collections

A pricing model in which a biller keeps a share of what the practice collects. We never price enrollment this way, since a practice still waiting on its effective dates collects nothing to take a share of. Billing and revenue cycle work is priced from the practice's own numbers, in the agreement. When each model is fair.

PHI

Protected health information: anything that identifies a patient together with their health, care or payment for care. HIPAA governs who may hold it. The free review works from practice facts only and needs none. Billing does, so a business associate agreement is signed first.

Prior authorization

A payer's approval required before a service, as a condition of paying for it. Physicians report about 40 of these requests each week, and physicians and staff together spend about 13 hours a week on them.^J Without the approval on file, a correct claim for a covered service is denied.

Re-attestation to underpayment.

Re-attestation

The provider confirming, on a set cycle, that everything in the CAQH profile is still true. A profile past its attestation date reads as out of date, and a payer reviewing the file stops until it is brought current. We note when each profile comes due.^A

Re-credentialing

A payer checking an enrolled provider's credentials again, on the payer's own cycle. It draws on the same CAQH profile, which is one more reason to keep that profile current between applications.

Reassignment

In Medicare, a clinician's instruction that payments for their services go to the practice. It needs an enrolled practice and an enrolled clinician to attach to, which is why it is filed last. Without it, a claim billed under the group has no path to the group's account.

Revalidation

Medicare's requirement that every enrolled provider and supplier confirm their enrollment again on a cycle CMS sets. CMS posts each due date. A missed one can end the ability to bill Medicare until the enrollment is restored.

Service line

One service a practice offers or plans to add, looked at the way payers see it: the codes it bills under, which plans cover it, and what each wants on file first. How we answer a service line question.

Single-case agreement

A payer's agreement to cover one patient's care with a provider who is not in its network, usually while credentialing is pending. The payer decides, and it is usually tied to a gap in its network or to continuity of care. It covers that one patient. It does not put the provider on the panel.^B

Tax ID

The Employer Identification Number the IRS issues to the practice. The legal name that goes with it has to match on every application, every contract and every claim.

Underpayment

A payment below what the contract or fee schedule says the payer owes for that code. It arrives looking like a paid claim, so only a line-by-line check against the expected amount finds it. We compare every paid line, and take the short ones back to the payer.

Where the specifics come from.