Claims Terminology

5. Claims that get corrected (after provider request/audit review, called adjustment) which results in either a payment to the provider or recoupment from the provider
7. Two or more procedures that have been rendered by the physician or facility on the same date of service.
9. A fixed payment paid per patient enrolled over a defined period of time, paid to a health plan or provider.
11. When a provider requests that the denial of their claim(s) be reconsidered, that is when a claims reconsideration comes into play
13. Request for anticipated payment: RAPs get submitted no more than 5 days after the home health agency performs their initial assessment of the Veterans’ needs and anticipated therapeutic support.
14. Electronic Remittance Advice: An electronic version of an insurance EOB that provides details of insurance claim payments.
15. Utilization management: This is where the Prospective UM application is stored, which will provide access to the referals within Facets.
16. Recovering funds paid to a provider, either partial or in full. This happens because the provider got overpaid.

1. Claim has paid over units allowed. Upon review, this claim may be subject to recoupment.
2. Submitting several CPT treatment codes when only one code is necessary.
3. Medical billing term for a complete submitted insurance claim that has all the necessary correct information without any omissions or mistakes that allows it to be processed and paid promptly.
4. A 2 character code (alpha-numeric) to a CPT treatment code that provide additional information to insurance payers for procedures or services that have been altered or modified in some way.
6. A data fix is when an invoice gets modified. It does not affect a claim, and is just like an adjustment but on the back end instead of the front end.
8. Carve-outs occur when a provider has a special contract or there is a specific service within the contract that is set aside or “carved out” for that code or provider.
10. Fee Schedule: Cost associated with each CPT treatment billing code for a providers treatment or services. Also called Physician Fee Schedule (PFS).
12. Clinical Editing Software: The tool used to validate proper billing of claims and the accuracy of units billed.
17. Claim form for hospitals, clinics, or any provider billing for facility fees similar to CMS 1500.