Glossary

Administrative users (administrators) are able to control all access to the system, including adding/removing users and their privileges.

The amount that the insurance payer is willing to cover.

ANSI X12 is a set of standards developed by the American National Standards Institute for electronic data interchange (EDI). It defines the format and structure for exchanging business transactions, including the 837 transaction set commonly used in healthcare for claims submission.

API stands for "Application Programming Interface". An API is a tool or tools that enable different software applications to communicate with each other. If configured correctly, systems can transmit and receive claims and ERA automatically via the API method. 

"An 'atypical' provider in the context of NPI refers to a healthcare provider or entity that, for various reasons, does not possess a National Provider Identifier (NPI)."

Codes explaining why a claim or service line was adjusted or denied.

The total amount billed for the services.

A claim is a request for a reimbursement submitted by a healthcare provider to a payer, such as an insurance company or government agency. The claim includes information about the medical services provided to the patient, the costs associated with those services, and any relevant patient information.

Claim Grouping refers to customizing how to group claims and ERA based on user-specified criteria. For example, a group can be made for both "Paid" and "Un-paid" ERA or a group can be made for "Rendering Provider NPI. Once created, these groupings are then applied as filters in Reporting and the View ERA page.

"Credentialed" in healthcare refers to the approval process where a provider is recognized by a payer, such as an insurance company, to submit claims for reimbursement. It involves verifying the provider's qualifications and compliance with the payer's standards before allowing them to bill for medical services.

The date when the healthcare service was provided.

A brief description of the reason for denial. This offers further clarification about the denial reason.

A specific code that indicates why the claim was denied. These codes are standardized and can provide insight into the nature of the denial (e.g., coding errors, lack of medical necessity).

Direct Data Entry refers to manually entering claim data into a form in Claim.MD. This is one method used to enter data. Other methods are uploading a batch file, SFTP, and API.  

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EFT, or Electronic Funds Transfer, is the electronic transfer of funds between bank accounts, commonly used in medical billing for streamlined payment transactions. A "Check" refers to a traditional paper instrument authorizing the payment of a specified amount and is occasionally utilized in medical billing as an alternative payment method.

EFT # stands for Electronic Funds Transfer Number. It is a unique identifier associated with an electronic funds transfer transaction, facilitating the tracking and verification of digital payments between financial institutions.

In most cases, billers are required to register their providers with the payers to whom they will submit claims and from whom they'll receive ERA and Eligibility information. This enrollment process can happen automatically or may involve billers completing specific forms to facilitate claims transmission and ERA reception.

ERA stands for Electronic Remittance Advice. It is an electronic document that healthcare providers receive from insurance payers which contains detailed information about payments and adjustments made to healthcare claims.  Sometimes adjustments or denials will be included, if any. 

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HCFA, or Health Care Financing Administration, commonly refers to the CMS-1500 paper claim form used for billing health insurance. In the electronic realm, the equivalent format is the 837 Professional Health Care Claim.

HIPAA, or the Health Insurance Portability and Accountability Act, is a U.S. federal law that sets standards for the protection of individuals' sensitive health information and ensures the privacy and security of such data in the healthcare system.

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This process begins with uploading a batch file, usually in X12 format, generated from a practice management or another system. The file is first uploaded to the "Upload Files" page and is subsequently parsed, with fields generated from the information within the uploaded file.

NCCI stands for National Correct Coding Initiative. It is a program developed by CMS to promote proper coding and payment of medical claims submitted to Medicare. It is designed to prevent improper coding practices. 

NPI stands for National Provider Identifier, which is a unique identification number assigned to healthcare providers in the United States. The NPI number is a 10-digit numeric identifier that is used in standard transactions by covered entities such as health plans, healthcare clearinghouses, and certain healthcare providers.

The NPPES stands for the National Plan and Provider Enumeration System. It is a database maintained by the Centers for Medicare & Medicaid Services (CMS) in the United States. The NPPES is used to assign unique identification numbers to healthcare providers, including individual practitioners and organizations. The primary identifier issued by NPPES is the National Provider Identifier (NPI), a standard 10-digit numerical identifier that is unique to each healthcare provider. 

The Payer ICN (Internal Control Number) is a unique identifier assigned by the payer (insurance company or government health program) to a specific insurance claim. It helps track and manage the processing of that particular claim, facilitating communication and reference between healthcare providers and payers.

Organizations that are responsible for reimbursing healthcare providers for the services they render to patients. Examples include private insurance companies, Medicare, Medicaid, and other third-party payers.

The payment date is the date on which a payment is made, indicating when funds are transferred or a check is issued as a settlement for a bill, invoice, or insurance claim.

The PCN (Processor Control Number) is a unique identifier assigned by the biller or healthcare provider to a specific insurance claim. It aids in tracking and managing the processing of the claim on the provider's end, distinguishing it from the Payer ICN (Internal Control Number), which is assigned by the insurance payer.

A policy number (or policy ID) is a unique identifier assigned to an insurance policy. It serves as a reference number that helps insurance companies and policyholders track and manage specific insurance contracts.

A practice management system (PMS) is a software tool used by healthcare providers to manage various aspects of their practice, such as scheduling appointments, patient registration, billing and claims documentation, and other administrative tasks. Often, claim batch files can be generated from these systems and then uploaded manually into Claim.MD. Alternatively, API and SFTP can be setup to automatically transmit claims directly from and receive ERA directly to the PMS system.

The healthcare organization or person that bills the payer (insurance company or government entity such as Medicare) for the services rendered to the patient. A provider generally has a billing NPI number identifier that is used for medical claims and ERA.

Details about the healthcare provider who rendered the services.

A unique identifier assigned to healthcare providers by Medicare for billing purposes. To look up Medicare information, including PTAN, visit this website: https://pecos.cms.hhs.gov/pecos/login.do#headingLv1 

Codes that provide additional explanations for adjustments described by Claim Adjustment Reason Codes (CARCs) or convey information about remittance processing. X12

The received date in the context of billing refers to the specific date when a document, such as an insurance claim or invoice, is officially received by the intended recipient, often an insurance company or a billing department.

These are notifications in Claim.MD for ERA denials from either pre-adjudicated or post-adjudicated claims. 

"Rejected claim last response" refers to the final communication from an insurance payer indicating that a submitted medical claim has been declined, often due to errors or issues. It signals the need for corrective action before resubmitting the claim for processing.

A secondary claim typically refers to a claim submitted to a secondary insurance provider after the primary insurance provider has processed the initial claim. It involves the coordination of benefits when a patient is covered by more than one insurance plan. The secondary claim includes information about what the primary insurance covered, and the secondary insurance provider processes the claim based on the remaining balance.

SFTP stands for "Secure File Transfer Protocol" which is a secure method for transferring files between computers over a network. If this is configured correctly, this method will enable claims and ERA to be transmitted and received automatically between systems. 

When this setting is enabled, it requires claims to be approved before transmitting. If not checked, valid claims will be marked for transmit immediately with no final approval necessary.

UB-04, also known as CMS-1450, is the standard paper claim form for institutional providers like hospitals. In the electronic domain, the corresponding format is the 837 Institutional Health Care Claim.

In software, a user type typically refers to a classification of users based on their level of access or permissions within the system. User types are used to control what actions a user can perform, what data they can access, and what settings they can modify, among other things. Examples of user types in Claim.MD include Administrator, Standard, Accounting/Invoices, and Eligibility Only.

"Zero pays" in healthcare or insurance terminology refers to situations where an insurance company does not provide any reimbursement for a particular medical service or claim.

The existing format for X12 EDI transactions is now 5010, having replaced the prior version, 4010, which became obsolete on January 1, 2012. Although some outdated PMS systems may still rely on 4010, it is recommended to upgrade to 5010 to comply with HIPAA regulations and avoid potential submission problems with claims. 

The file format used for transmission for ERA. This is the most common format for transmitting ERA between electronic systems. 

The 837 refers to the ANSI X12 transaction set used in electronic data interchange (EDI) to transmit healthcare claim information. It standardizes the format for submitting health insurance claims electronically.