A formal request made by a healthcare provider (such as a hospital, doctor, or other medical professional) to an insurance company or payer for reimbursement of services rendered to a patient.
An individual or entity that delivers medical services or supplies to patients. This includes hospitals, physicians, nurses, therapists, clinics, and other healthcare professionals.
An organization that provides health insurance coverage and processes claims for medical services on behalf of policyholders. This can include private insurance companies, government agencies (such as Medicare or Medicaid), or self-insured employers.
The process by which a healthcare provider receives payment from an insurance company or payer for services rendered to a patient. Reimbursement rates may vary based on factors such as insurance coverage, negotiated contracts, and the type of service provided.
The process of assigning standardized codes to medical diagnoses, procedures, and services for billing and reimbursement purposes. Common coding systems include ICD (International Classification of Diseases) for diagnoses and CPT (Current Procedural Terminology) for procedures.
The act of sending a completed claim form along with supporting documentation (such as medical records and itemized bills) to an insurance company or payer for review and processing.
The process by which an insurance company or payer evaluates a submitted claim to determine its eligibility for reimbursement. This includes verifying patient eligibility, assessing the medical necessity of services provided, and applying coverage rules and payment policies.
The rejection of a claim by an insurance company or payer, either partially or in full, due to reasons such as incomplete information, lack of medical necessity, or coverage limitations. Denials may be appealed by the healthcare provider if they believe the decision was made in error.
The formal process by which a healthcare provider challenges a claim denial or reimbursement decision made by an insurance company or payer. Appeals typically involve providing additional documentation or rationale to support the original claim submission.
A document provided by an insurance company or payer to the healthcare provider detailing the outcome of a claim submission, including the amount paid, any adjustments or denials, and reasons for those decisions.
The process by which multiple insurance plans determine their respective responsibilities for covering healthcare expenses when a patient is covered by more than one insurance policy. COB rules help prevent overpayment and ensure appropriate sharing of costs between insurers.
Unlawful or unethical practices related to healthcare claims, such as submitting false information, billing for services not provided, or engaging in kickback schemes. Fraud and abuse can result in financial penalties, legal consequences, and damage to the reputation of healthcare providers and insurers.
A payment model that incentivizes healthcare providers to deliver high-quality, cost-effective care by linking reimbursement to patient outcomes, rather than the volume or intensity of services provided. Value-based reimbursement aims to promote better health outcomes and reduce unnecessary healthcare spending.
Claims submitted for healthcare services delivered remotely via telecommunications technology, such as video conferencing or secure messaging platforms. Telemedicine claims may have specific billing codes and reimbursement policies established by insurers to accommodate virtual care delivery.
Federal legislation that establishes privacy and security standards for protecting patients’ personal health information (PHI). Healthcare providers and insurers must comply with HIPAA regulations when handling claims and other patient data to safeguard confidentiality and prevent unauthorized access or disclosure.