Claims
Claims
A medical claim is an itemized bill or invoice submitted by a healthcare provider (doctor, hospital, clinic) to a patient's insurance company after a visit, requesting payment for services rendered. These claims contain specific medical codes, including diagnoses and procedures, that allow insurers to determine coverage and reimburse the provider, with any remaining balance often billed to the patient.
Claim Process
Typically, in-network providers submit claims directly to the insurance company on behalf of the patient.
KPI
Key performance indicators
IPA
Independent physician association (ex: OCN Inland Valley)
PQI (Abbreviation)
Performance Quality Improvement
Professional claim (a.k.a. “provider/physician” claim)
Institutional claim (a.k.a. “facility” claim)
A claim billed for services performed by an individual clinician/provider (or provider group), such as a doctor, specialist, therapist, or other professional.
A claim billed for services provided by a facility (the “place” where care happens)like a hospital, ER, SNF, or outpatient hospital department.
Claim outcome
After reviewing the claim, the insurer sends an Explanation of Benefits (EOB) and pays the provider directly or reimburses the patient if they paid upfront.
ACW
After call work 30 Seconds
Par & Non Par
Participating provider and Nonparticipating provider
PQI (used for)
PQI are used to improve organizational services and performance. It is a way for a member’s voice to be heard. PQI’s are sent to auditing team to further review.
Configuration
Config requests are only for EOC’s and document updates; which hp updates the medical group with updated benefits/plan.
Maximum Out of Pocket
An out-of-pocket maximum is the absolute highest amount you will pay for covered, in-network medical services in a plan year. Once you spend this amount on deductibles, copayments, and coinsurance, your health insurance covers 100% of costs for covered benefits, acting as a financial safety net.
AVG hold time
2 Minutes
Auth
Authorization
What is DMHC (Department of managed health care) definition of PQI
“A written or oral expression of dissatisfaction regarding the plan and/or
provider.”
Claim purpose
To request payment from insurance companies for services, supplies, or devices provided.
Evidence of coverage
Is a detailed document provided by health insurance plans, It serves as a legally binding handbook that outlines:
Covered services
Limits and exclusions
Cost sharing
Rights and responsibilities
Annual updates
Adherence
95%
COB
coordination of benefits
What qualifies as a PQI?
Dissatisfaction of experience with a provider (such as; Doctor or staff)
Complaint they cannot reach the office via phone
Dissatisfaction with how an auth/claim was processed
What is included in the claim
Claims contain patient demographics, provider information, diagnosis codes (ICD-10), and procedure codes (CPT/HCPCS).
Explanation of benefits
It is a document provided by insurance/medical group payers that outlines how a healthcare claim was processed, detailing the costs shared between the patient and the health plan. This document helps patients understand their financial responsibilities for the services received.
EOBS can be requested to be mailed out to the member/patient only
We do not send Health plan EOBS
They can be in a date range (Ex: 1/1/2026 – 4/10/2026)
How do you report an absence
Text 888-863-0090 or call 855-317-0842
AMT
Amount
Who can the PQI be about?
Doctor
staff
facility
Medical group IPA