| Term | Definition |
| Abuse | Billing patterns and practices that are excessive or unnecessary but not fraudulent |
| Coinsurance | Predetermined percentage the patient is responsible to pay for covered services once the annual deductible has been met |
| International Classification of Disease 10th Edition Clinical Modifier (ICD-10-CM) | List of codes used to report and classify diseases, conditions, and other reasons for health care encounters |
| Third Party Payer | Health care insurance company that reimburses services provided by providers and/or health care organiztions |
| Deductible | Annual amount the patient must pay before the insurance will begin to pay for covered benefits |
| Current Procedural Technology (CPT) | Descriptive definitions used to explain procedures and services provided to the patient |
| Preauthorization | Process of requesting approval for a service or procedure by providing medical history to the insurance to support the medical need for the surgical procedures |
| Precertification | Process of determining a patient's coverage details for health care services (lab imaging services, hospitalizations, surgical procedures |
| Appeals Process | A process used to request review of a claim that was denied- to determine if the denial was due to a billing error; if so, file an appeal at the lowest level; and then move up to higher levels if needed |
| Revenue Cycle Management | Process that health care providers use to manage financial viability by increasing revenue, improving cash flow, from registration to final payment |
| Place of Service (POS) | Two-digit code that identifies where the services were performed |
| Covered Entity | Entity that transmits health information in electronic form (ex. providers, health plans, clearinghouses) |
| Assignment of Benefits | Methods of a patient requesting their claim benefits be paid to the health care organization that provided the service |
| Adjudication | The process where the insurance company receives a claim and makes a determination on payment or denial |
| Auditing Process | The act of reviewing and comparing the patient medical records and claims to assess for coding appropriateness and completeness of the medical documentation |
| Medical Necessity | Process of providing diagnosis codes that support the services rendered to the patient; coding for medical necessity involves associating applicable ICD-10:CPT codes within the billing software, which is referred to as "linkage/linking" |
| Utilization Management | Method used to control health care cost, by reviewing the appropriateness and medical necessity of services rendered to the patients prior to the treatment being performed |
| Health and Human Services | Government department that oversees the health of the community and provides crucial services to |
| Eligibility | Process of verifying the patient has insurance coverage and has benefits for the services to be provided |
| Encounter Form | Document that captures diagnoses or procedure codes for the services provided during the patient's encounter (electronic or paper format) |
| Health Insurance Portability and Accountability Act (HIPAA) | Federal act that governs and mandates regulations that include privacy, confidentiality, and security for health care data and information |
| Out of Pocket Payment | Patient responsibility portion of a health insurance plan defined by the payer (INC. annual deductible, copay, and coinsurance amounts) |
| Protected Health Information | Individually Identifiable Patient Information |
| Beneficiary | Person eligible to receive benefits for covered services once the annual deductible has been met |
| electronic data interchange (EDI) | Computer technology that contains the exchange of data between the health care provider and payer |
| Noncompliance | The act of disregarding rules and guidelines outlined by state and federal government agencies and third-party agencies |
| Denied Claim | A claim returned for a third-party payer because of technical errors patient coverage errors |
| Fee-for-Service | Cost or fee that is charged for each individual service |
| Accounts Recievable | The amount owed to a provider for health care services rendered |
| Explanation of Benefits | Document that explains how the payer processed the claim for ; Remittance Advice |
| Allowed Amount | The maximum amount an insurance company will pay for the service for the service, procedure, or supply |
| Officer of Inspector General | Government department that investigates fraud and abuse |
| Copayment (Copay) | Flat, fixed amount that a patient pays for specific services (ex. office emergency department encounters) |
| Coding Compliance | The conformity and adherence to established coding guidelines and regulations |
| Fraud | Internationally billing for services not performed, reporting fraudulent diagnosis, or medical coding errors |
