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Decoding Healthcare Billing: A Comprehensive Glossary

Navigating the maze of healthcare billing can be quite a challenge, especially with the plethora of acronyms and terms used in this industry. To help you understand and manage this crucial aspect of healthcare more effectively, we've compiled an extensive list of commonly used terms and their definitions. 835 File: This is an electronic ERA (Electronic Remittance Advice) file. It provides details about providers' claims payment and, if denied, contains the required explanations. 837 File: An electronic EDI (Electronic Data Interchange) file. It allows for the electronic interchange of business information using a standardized format. Adjudication: The process insurance companies use to determine what to pay you and why. Adjustment: The mandatory "write-off" determined by an insurance company. Billing Provider: The entity getting paid for the rendered service. It's mentioned in Box 33 on the CMS-1500. Classes: A flexible way to define sessions, clients, or payments. Contracted Rate: The predetermined reimbursement rate for a service, i.e., what insurance pays you. COB (Coordination of Benefits): This allows plans that provide health coverage to determine their respective payment responsibilities when an individual is covered by more than one plan. Credentialing: The process of obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services in or for a healthcare organization. CPT Code (Current Procedural Terminology): A billing code that represents either a procedure or supply. DOS (Date of Service): The date the insured was seen by a healthcare practitioner or given medical treatment. Diagnosis Pointer: Indicates what diagnosis code you were treating with which CPT. EDI (Electronic Data Interchange): The electronic interchange of business information using a standardized format. EFT (Electronic Funds Transfer): The electronic transfer of money from one bank account to another, either within a single financial institution or across multiple institutions. ERA (Electronic Remittance Advice): An electronic data interchange (EDI) version of a medical insurance payment explanation. EOB (Explanation of Benefits): A statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf. CMS-1500: The standard paper claim form used to bill the Centers for Medicare and Medicaid services for services provided to patients. HL-7 (Health Level 7): The format in which the WebPT Data comes to Therabill. Payer: The insurance company. Provider: The therapist. Remark Code: A code explaining why an insurance company adjudicated the service a certain way. Rendering Provider: The therapist who performed the service. It's mentioned in Box 24J on the CMS-1500. Secondary: A second Insurance Plan. Service Code: A valid CPT Code. Service Facility: The location where the service(s) took place. It's mentioned in Box 32 on the CMS-1500. Session: A Date of Service. TIN (Tax ID Number): The Billing Provider's Federal Tax ID. It's mentioned in Box 25 on the CMS-1500. Taxonomy Code: Identifies the provider’s specialty. Tertiary: A third insurance Plan. By familiarizing yourself with these terms, you'll be better equipped to navigate the complex world of healthcare billing and make informed decisions about your practice.

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