Whether you’re new to medical billing, practice management or claims auditing, or you just need a refresher, this article will remind you of those pesky acronyms you’re trying to learn or remember.
Pro-tip: Feel free to use Command + F keys (on Mac) or Control + F keys (on Windows) to search and find the keywords you’re looking for!
ASC: Ambulatory Surgery Center
An outpatient health care facility that is more than a medical office but less than a full-fledged hospital.
ATD: Applied to Deductible
The amount of money a patient owes to a provider that goes to paying their annual deductible.
AOB: Assignment of Benefits
Insurance payments paid directly to the healthcare provider for medical services administered to a patient. This occurs after a claim has been successfully processed.
CARC/RARC: Claim Adjustment Reason Code/Remittance Advice Remark Code
CARCs describe why a claim or service line was paid differently than it was billed.
RARCs provide additional explanations for an adjustment already described by a CARC (supplemental RARCs) or convey information about remittance processing (informational RARCs or Alerts).
Claim Adjustment Group Codes generally assign responsibility for the adjustment amounts. The format is always two alpha characters.
The values and definitions are as follows:
CO: Contractual Obligation
CR: Corrections and Reversal
Note: This value is not to be used with 005010 and up.
OA: Other Adjustment
PI: Payer Initiated Reductions
PR: Patient Responsibility
COB: Coordination of Benefits
This is which insurance agency is the primary provider versus the secondary provider when a patient has more than one policy.
CPT: Current Procedural Technology
Numeric coding system maintained by the American Medical Association that describes medical services and procedures. You’ll use them to bill insurance programs for reimbursement.
DCI: Duplicate Coverage Inquiry
When an insurance provider contacts another to see if they’re currently providing specific coverage.
DOS: Date of Service
When a service took place.
EDI: Electronic Data Interchange
The electronic network that collects information before delving it out to particular individual insurance providers.
EFT: Electronic Funds Transfer
Transferring money electronically. A credit or debit charge or transfer must take place.
EMR: Electronic Medical Records
Digitally formatted health records. Also known as the complete record of a patient that is sent to a healthcare provider and/or insurance agency.
EOB: Explanation of Benefits
A document attached to a processed claim that explains to the provider and patient what the insurance company provides, usually consisting of covered charges, payment methods, deductibles, patient responsibility and potential write-offs.
ERA: Electronic Remittance Advice
A digital version of an EOB; a document describing how much of a claim the insurance company will pay or why the claim was denied.
FDCPA: Fair Debt Collection Practices Act
Law that explains the guidelines for creditors and collections agencies trying to collect from delinquent accounts.
Providers charge for every service they provide; a model that at times causes over testing for reimbursement.
FI: Fiscal Intermediary
A medicare official/representative that handles Medicare claims and cases.
HCPCS: Healthcare Common Procedure Coding System
Level I is CPT-4 codes that are for medical services and procedures.
Level II is for products, supplies and services not otherwise included (ambulance services, DME, prosthetics, orthotics or supplies used outside a doctor's office).
HIPAA: Health Insurance Portability & Accountability Act
Privacy rule of the health industry that outlines the use and/or distribution of personal health information for specific organizations.
HIPAA law was passed in 1996. Title I of the act protects workers’ health insurance when they change or lose jobs. Title II of the Act established standards and best practices in electronic health care.
HMO: Health Maintenance Organization
A healthcare policy that requires a gatekeeper or primary care physician. If a situation calls for further action, this gatekeeper will refer the patient to a different specialist.
ICD-10: International Classification of Diseases, Tenth Revision
A clinical cataloging system owned and developed by the World Health Organization (WHO) that went into effect for the U.S. healthcare industry in 2015. The ICD-10 offers codes for the newest possibilities in healthcare in every revision.
A medical care provider that is contracted with the specific insurance provider used by a patient.
MACRA: Medicare access and CHIP reauthorization Act
Created the Quality Payment Program that:
N/C: Non-Covered Charge
A healthcare service that is not covered by the insurance policy.
NEC: Not Elsewhere Classifiable
The abbreviation used on ICD forms when the information given does not permit a more refined assignment.
NDC: National Drug Code
A universal, 10-digit product identifier for human drugs in the United States. The code is present on all nonprescription (OTC) and prescription medication packages and inserts in the U.S.
NPI: National Provider Identifier
A unique ID number for certain health care providers.
OON: Out of Network
A medical service provider that does not currently work with the specific insurance agency.
PA: Prior Authorization
Approval from a health plan before a patient can obtain a medical service or fill a prescription in order for the service/prescription to be covered by a patient’s health plan.
PCP: Primary Care Physician
A doctor selected by the member to be the first physician contacted for any medical problem. The doctor acts as the member's regular physician and coordinates any other care the member needs, such as a visit to a specialist or hospitalization.
PHI: Protected Health Information
Basic patient information that remains classified. Examples of PHI include name, date of birth, social security number, insurance ID, medical records and telephone numbers.
RBRVS: Resource Based Relative Value Scale
Determines how much money medical providers should be paid. It is partially used by Medicare in the United States and by nearly all HMOs.
RVU: Relative Value Unit
Used by Medicare to determine the amount of reimbursement providers are owed; a way of standardizing and comparing service volumes across all continuums.
SPC: Statistical Process Control
A charge entry term that’s been applied to healthcare quality improvement, and to examine the benefits, limitations, barriers and facilitating factors related to such application.
SQC: Statistical Quality Control
A charge entry term used to review process quality through a random audit.
TIN: Tax Identification Number
The specific number assigned to an individual for tax filing and tracking purposes.
UCR: Usual Customary & Reasonable
The coverage limitations set in place by an insurance patient. Limits the maximum amount of funding a company will pay for a service.
WC: Workers’ Compensation
A work-related injury insurance claim.
ACO: Accountable Care Organization
CDHP: Consumer-driven Health Plan
Members receive PPO-like benefits, but only after they’ve paid their deductible. This deductible is generally quite high, but usually comes with low premiums and a health savings account. Money from this account can be used to help pay for out-of-pocket expenses.
CMS: Centers for Medicare and Medicaid Services
Medicare and Medicaid are different, though both are referred to as CMS. The biggest difference between these is in reimbursement. On average, Medicaid pays out an estimated 61% of what Medicare does nationally for outpatient physician services, according to a study by Forbes.
COBRA: Consolidated Omnibus Budget Reconciliation Act (of 1985)
A federal law that requires employers (with 20 or more employees) to offer continued health insurance coverage to eligible employees + their beneficiaries whose group health insurance has been terminated under certain circumstances.
EPO: Exclusive Provider Organization
A type of health plan that offers a local network of doctors and hospitals for you to choose from. An EPO has lower premiums and higher deductibles than a PPO plan, but an EPO will generally not cover out of network providers (except in an emergency).
HMO: Health Maintenance Organization
A group of medical insurance providers that limit coverage to medical care provided through doctors and other providers who are under contract with the HMO. Members will need to first obtain care from a PCP before seeing other providers.
IPA: Independent Practice Association
A professional organization of physicians and/or healthcare providers who have a contract with an HMO. HMOs contract IPAs to provide services to patients within the HMO’s network, but their individual practices do not have to be part of the HMO network.
MCO: Managed Care Organization
A health care company or a health plan that is focused on limiting costs, while keeping quality of care high. PPO, EPO, HMO and POS plans are considered MCOs.
POS: Point of Service
A health plan that’s a hybrid of HMOs and PPOs. Members get the flexibility to see in- or out-of-network doctors like a PPO, but their share of the costs will be higher. Like an HMO, they may be required to see a PCP before seeing a specialist.
PPO: Preferred Provider Organization
A health plan that covers in and out-of-network providers, though in-network providers are generally cheaper for the patient. PCP referrals may not be required and most preventative care is covered at 100%.
TOP: Triple Option Plan
A health plan referred to as a “cafeteria plan.” Individuals get to decide between HMO, PPO or POS coverage. PPO plans are generally the most expensive and HMO plans the least expensive.
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