835 Electronic Remittance— The electronic file from the payor (i.e. Medicare) that provides claim payment information.
837 Electronic Bill— Standard format for transmitting health care claims electronically.
Adjudication— The determination of the insurer's payment or financial responsibility after the member's insurance benefits are applied to a medical claim.
Aging— Insurance claims that haven’t been paid or balances owed by patients overdue by more than 30 days.
Ancillary Services— Any service administered in a healthcare facility (other than room and board), including biometrics tests, physical therapy, and physician consultations among other services.
AOB(Assignment of Benefits) — Insurance payments made directly to a healthcare provider for medical services received by the patient.
Batch— A collection of individual claims.
Bill Type— References Locator 4 on the UB04 claim form which contains the Type of Bill.
Charge— A single billable service performed for a patient.
Claim Batch— A statement of one or more charges for a patient requesting payment from a Payor.
EOB(Explanation of Benefits) — Attached to a processed medical claim wherein the insurance company explains the services it will cover for a patient’s healthcare treatments. It may also explain what is wrong with a claim if it’s denied. May also be known as Remittance Advice (R/A).
Episode— The unit of payment for HH PPS covering up to 60 days of Home Health Services.
ERA— The digital version of EOB, which specifies the details of payments made on a claim either by an insurance company or required by the patient.
Exclusion— An individual claim that is removed from a batch to avoid billing with the batch and creating AR.
FFS(Fee-for-Service) — A type of health insurance wherein the provider is paid for every service they perform.
Final— The final claim for an episode listing the actual services provided during the 60-day episode to be reimbursed.
Hold— A setting placed on a claim in a batch indicating it will be billed at a later time. This allows the A/R to be posted to the patient account without actually sending the claim to the payor.
LUPA(Low Utilization Payment Adjustment )
NOE(Notice of Election - 81A/82A) — A Hospice transaction that must be keyed online to Medicare prior to sending a beneficiaries first claim for payment. The NOE updates the patient’s Medicare eligibility and establishes the provider furnishing care. NOE transactions will process online into a P status but no Medicare reimbursement will be issued for the NOE.
RAP(Request for Anticipated Payment) — The first claim for an episode which establishes the Home Health episode and projects the services that will be performed during that episode with the reporting of the HHRG/HIPPS code.
Sequential Billing— Hospice billing must adhere to sequential billing, meaning that there cannot be a claim pending or finalized with a through date more than one day less than the current claims from date.
Sequestration— Mandatory Payment Reductions in the Medicare Fee-for-Service (FFS) Program (“Sequestration”). The Budget Control Act of 2011 requires, among other things, mandatory across-the-board reductions in Federal spending, also known as sequestration.