The process of evaluating and determining the validity, accuracy, and reimbursement eligibility of healthcare claims submitted by patients, providers, or healthcare facilities.
A request for payment submitted by a healthcare provider to an insurance company or payer for services rendered to a patient.
An entity responsible for processing and reimbursing healthcare claims, typically an insurance company, government agency, or healthcare plan.
A healthcare professional or facility that delivers medical services or supplies to patients, including hospitals, physicians, clinics, and pharmacies.
The payment made by a payer to a healthcare provider for services rendered to a patient, as per the terms of the insurance policy or healthcare plan.
The process of confirming a patient’s coverage and benefits under their insurance plan, ensuring that services rendered are covered and reimbursable.
The assignment of alphanumeric codes to describe medical diagnoses, procedures, and services provided during a patient encounter, facilitating accurate billing and claims processing.
A predetermined list of prices or reimbursement rates for specific medical services and procedures, used by payers to determine reimbursement amounts.
Evaluation of the appropriateness and necessity of medical services provided to patients, ensuring quality of care while controlling costs.
The software or platform used by payers to process and adjudicate healthcare claims efficiently, incorporating rules, guidelines, and algorithms to determine payment outcomes.
The rejection of a healthcare claim by a payer, typically due to lack of coverage, coding errors, or failure to meet reimbursement criteria.
The process by which a healthcare provider or patient challenges a denied claim, seeking reconsideration and justification for reimbursement.
The process of determining primary and secondary payers when a patient is covered by multiple insurance plans, ensuring proper reimbursement and avoiding overpayment.
The electronic exchange of healthcare information, including claims, between providers, payers, and other healthcare stakeholders, improving efficiency and accuracy in claims processing.
The identification and prevention of fraudulent or abusive practices in healthcare claims, safeguarding against financial losses and maintaining integrity in the healthcare system.
The requirement that healthcare services and procedures be reasonable and essential for the diagnosis or treatment of a patient’s condition, influencing reimbursement decisions.
A document sent by a payer to a provider detailing the status of processed claims, including payment information, denials, and adjustments.
Expenses incurred by patients for healthcare services not covered by insurance, including deductibles, copayments, and coinsurance.
Metrics used to assess the effectiveness, safety, and patient outcomes of healthcare services, guiding reimbursement policies and provider performance evaluations.
A payment model that ties reimbursement to the quality and effectiveness of healthcare services provided, incentivizing better patient outcomes and cost-effective care delivery.