Billing Basics
This 10-digit number is uniquely assigned to healthcare providers and is required on all standard claim forms.
What is an NPI (National Provider Identifier)?
These 5-digit codes are used to identify the specific medical procedures and services performed by healthcare providers.
What are CPT codes? (Current Procedural Terminology)
This critical first step in the revenue cycle happens before the patient even sees a clinician to verify their insurance coverage.
What is Eligibility Verification? (Accept: Registration / Pre-registration)
This federal health insurance program primarily serves individuals aged 65 and older, as well as younger people with specific disabilities.
What is Medicare?
This common denial occurs when a hospital submits a claim after the insurance company's established window for accepting bills.
What is a Timely Filing denial?
This standard paper claim form is used specifically by institutional providers and hospitals for billing.
What is a UB-04? (Accept: CMS-1450)
This three-digit code on a UB-04 tells the insurance company exactly where in the hospital a service or supply was provided.
What is a Revenue Code?
This process involves getting advance approval from a health plan before a specific hospital procedure or stay can take place.
What is Prior Authorization? (Accept: Pre-authorization or Pre-cert)
This joint federal and state program provides health coverage to low-income individuals and families.
What is Medicaid?
This is the official request a hospital sends to an insurance company to reconsider a denied claim or incorrect payment.
What is an Appeal?
This is the fixed amount a patient must pay out-of-pocket for a specific medical service or prescription at the time of a visit.
What is a copayment? (Accept: Copay)
This classification system is currently used in the U.S. to code patient diagnoses and inpatient procedures.
What is ICD-10? (Accept: ICD-10-CM or ICD-10-PCS)
This is the process of reviewing a patient's medical record to ensure that the documented care justifies the medical necessity of the services billed.
What is Utilization Review? (Accept: Clinical Documentation Improvement / CDI)
This type of managed care plan generally requires patients to get referrals from a primary care physician and stay within a strict network of providers.
What is an HMO? (Health Maintenance Organization)
This type of rejection happens instantly at the clearinghouse level before the claim ever reaches the payer's adjudication system.
What is a Front-End Rejection?
This term refers to the annual amount a patient must pay for medical care before their insurance company begins to pay.
What is a deductible?
These two-digit extensions are added to CPT codes to provide extra details about a procedure without changing its definition.
What are modifiers?
This electronic report is sent by a payer to a hospital to explain the payment, adjustments, and denials for a batch of claims.
What is an ERA? (Electronic Remittance Advice / Accept: EOB)
This insurance plan is always billed last when a patient is covered by more than one health insurance policy.
What is the Secondary Payer? (Accept: Tertiary or Supplemental)
Payers issue this type of denial when they determine a service could have been safely performed in an outpatient clinic rather than an inpatient hospital bed.
What is a Medical Necessity denial? (Accept: Patient Level of Care denial)
This standard electronic transaction format is used to submit institutional healthcare claims electronically.
What is an 837I?
This coding system is used primarily for products, supplies, and services not included in the standard CPT code set, such as ambulance rides or durable medical equipment.
What is HCPCS? (Healthcare Common Procedure Coding System)
This metric measures the average number of days it takes a hospital to collect payment after a service is rendered.
What is AR Days? (Days in Accounts Receivable)
This term describes the rule used to determine the primary insurance plan for a dependent child when both parents hold health policies.
What is the Birthday Rule?
This rule prevents providers from billing a patient for the difference between the hospital's original charge and the insurance company's allowed amount.
What is Balance Billing? (or the No Surprises Act)