Adjudication
The insurance carrier process for evaluating a claim for payment; investigating details to determine which items & how much should be paid
Adjustment
A positive or negative change to a patient’s account balance (changes, corrections, discount write-offs)
Allowed charges
The maximum allowed
amounts for covered charges: the amount the payer will pay the provider for a particular service or procedure (also referred to as maximum allowed fee, allowed amount)
Appeal
Process used by provider to request the insurance reconsider claim denial. Supplies documentation that supports medical necessity.
Balance billing
Capitation plan
Charge-based fees
Bases fees on “usual, customary, and reasonable” (UCR) amounts, reflecting what providers in a specific geographic area typically charge for similar services.
Conversion factor
COB (coordination of benefits)
deciding which policy is the primary when there is more than one plan; carriers exchange information regarding payment to prevent overpayment & maximum is paid
ERA (electronic remittance advice)
An electronic version of EOB to providers. Electronic notice sent by insurance to accepting assignment provider with details of claim.
Excluded services
EOB (explanation of benefits)
Hard- copy sent by insurance to patient & provider (accepting assignment) after it has been processed; Shows service date, type, & charges filed; what was paid & any reasons for denials.
GPCI (geographic practice cost index)
Lifetime maximum
Manual review
Occurs when a claim is removed from an automated processing system & an examiner is to request addtl info to complete processing.
MCF (Medicare conversion factor)
MFS (Medicare fee schedule)
Nationally uniform relative
Out-of-pocket expenses
Pending claim
PMPM (per member per month)
Reason codes
RVU (Relative value unit)
Remark codes
