Glossary

This glossary describes the key concepts and terminology used throughout AveaOffice and is a good place to learn about terms you may see during your workflow process.

Adjustment Reason Codes 

Claim adjustment reason codes communicate an adjustment, meaning that they must communicate why a claim or service line was paid differently than it was billed. If there is no adjustment to a claim/line, then there is no adjustment reason code. A common example is PR-45 explaining the amount of patient responsibility. 

Reason codes are grouped into one of the following categories:

PR - Patient Responsibility
CO - Contractual Obligation
PI - Payer Initiated
CR - Correction and Reversal
OA - Other Adjustment

Appeals

When a patient or a provider tries to convince an insurance company to pay for healthcare after it has denied a claim, an appeal can be filed. However, a billing specialist can often convince an insurance rep to send the claim back for reprocessing without having to file an official appeal with the insurer. An appeal consists of a demand letter, UB04, POTF (proof of timely filing), and claim review/reconsideration forms at minimum.

Attendance

Days of treatments that the patient has attended can also be referred to as Attendance. In AveaOffice, we can mark attendance in the calendar view, and each patient has a running list of all treatments they have received.

Audit Records

For Managing Organization Admins, you can track the account and user changes that have been made by you and members of your staff. 

Specifically, the audit logs shows events related to the following:

• patient profile changes
• claim submissions
• claim follow-up updates
• payments

Authorization Numbers/Pre-Authorization/Retro-Authorization

Alphabetic and numeric codes that are obtained by the provider through the payer in order to authorize certain treatments for patients. Pre-authorization is obtained before services are rendered, while retro is after the services were rendered.

Batch

A group of claims that were submitted to the clearinghouse at the same time.

Bulk Update

A button on the Claims screen to update the workflow (status, follow-up date, issues, notes) of multiple claims at once.

Case Manager

For each utilization plan, we can assign a user as the person that originally obtained the authorization, or confirmed that no authorization was required. The UM Case Manager will manage all continuous authorizations for all plans for a patient. Both can be set and edited in the Scheduling and Utilization tab of a patient's profile.

Charges

The billed amount(s) for any given service on the claim. 

Claim Control Number 

The number assigned to identify the claim in AveaOffice. Claim control numbers usually begin with AV-XX-C00YYYYY. The "XX" in this case would identify the organization and practice that submitted the claim, and the "YYYYY" would identify the number of the claim. Each claim control number is unique. Note: You may see claim control numbers that do not follow this naming convention. It is highly likely these are legacy claims that were not created in AveaOffice, but the follow-up tracking is done in AveaOffice.

Claim Instance

The iteration of the claim submission in AveaOffice, notated at the end of the claim number as -1.1, -1.2, -1.3, etc. Secondary claim instances start with -2.1.

Claim Review/Reconsideration

Certain insurers provide forms called “Claim Review Forms” or “Claim Reconsideration Forms.” Similarly to demand letters, these forms are sent in after a claim is denied incorrectly the first time, and the billing specialist is unable to convince the insurance representative to send the claim back for reprocessing over the phone. Typically, these forms are used when insurers are requesting small adjustments to claims such as itemization. However, you can also attach these forms to appeals and medical records submissions to help the insurance companies process the claims quicker.

Claim Rule

An automation within AveaOffice to force claims to be processed a certain way. To learn more about claim rules, read our article here. 

Claim Summary

Similar to an EOB, Claim Summaries are documents sent out by the payers that outline how a claim was processed. They don’t always list each date of service or provide the same specific information that EOBs include. After confirming that a claim has processed and/or paid, we request either Claim Summaries or EOBs.

Clearinghouse

In medical billing, companies that function as intermediaries who forward claims information from healthcare providers to insurance payers are known as clearinghouses. In what is called claim scrubbing, clearinghouses check the claim for errors and verify that it is compatible with the payer software.

CMS-1500

The official form we use for filing professional/lab claims. These forms are submitted either electronically or paper via the clearinghouse.

COB - Coordination of Benefits

When a patient has more than one insurance plan, and the primary insurance plan denies the claim for “coverage,” we conduct a Coordination of Benefits to determine any secondary or tertiary insurance that may cover the procedure.

Co-Insurance

A percentage of coverage that the member must pay after the payer pays the contracted portion listed in their health plan. For example, a member might have a deductible with a 20% co-insurance. This means that after the member has satisfied their deductible requirements, they’ll be responsible for paying 20% of the remaining amount and the insurance company will pay 80%.

Co-Pay

Similar to a deductible, a co-pay is an agreed amount (written into the member’s policy) that the member must pay to the provider before receiving treatment.

Corrected Claim

When a claim is denied and the payer is requesting a change to the UB04/CMS-1500 form, we send in a corrected claim in order to have the claims processor re-process the claim with the requested/necessary changes.

Courtesy Bill

A courtesy bill is a claim submitted to a patient's insurance company by a medical service provider on the patient's behalf after the patient has self-paid in full for the services rendered during their visit.

Deductible

The specific amount a member/patient needs to pay before the insurance company begins to pay claims and cover procedures. For example, a member with a $100 deductible would need to pay out $100 on their claims before the payer starts to cover/pay for services. Deductibles can be applied per visit, per year, etc.

Demand Letters

Demand Letters are written when we submit appeals or submit medical records. A Demand Letter spells out the issues with the claim and demands the claim processor to process the claim in question based on the information provided.

Denials

A denied claim. Denials can occur for many reasons including coverage issues, payer problems, or filing issues.

Discontinued Claim

When a practice is discontinued from AveaOffice, all claims that were still open in the account are marked as "Discontinued".

DOS - Dates of Service

The dates that a provider performed the procedures listed on the UB-04/CMS-1500 form. Claims may have several dates of service or may have only one date of service depending on the account configuration.

Enrollment

Enrollment is required by most government payers for Professional and Institutional Claims and Eligibility. Enrollment is required by all payers for Remits. The enrollment process links the provider’s NPI, Tax ID, and/or Provider Number to the Submitter ID of the clearinghouse or another submitter who submits claims or eligibility inquiries to the payer or receives transactions on the provider’s behalf.

EOB - Explanation of Benefits

When we’ve confirmed that a payer has paid or denied a claim, we request an explanation of benefits to determine whether the claim was processed correctly. EOB’s typically include the claim number, the insured address, policy and patient information, and a breakdown of payments. They normally show each date of service, the billed amount, the patient/member responsibility, the paid amount, and the discounted amount. In other words, EOB’s specifically break down how a claim was paid or denied.
In-Network- When a provider has contracts in place with a payer for certain procedures, that provider is considered to be in-network for those procedures. In-network providers normally get reimbursed higher than out of network.

ERA - "Electronic Remittance Advice"

An Electronic Remittance Advice provides detail about the providers' claims payment, and if the claims are denied, it would then contain the required explanations.

HIPAA (Health Insurance Portability and Accountability Act)

The law outlining how certain entities like health plans, clearinghouses or facilities can use or disclose personal health information. Under HIPAA, patients must be allowed access to their medical records.

Home Plan

Most Blue Cross Blue Shield plans request that claims be sent to the local payer in the state where the facility is located. Most patients have a BCBS plan with a different state than the location of the facility. This plan is called the Home Plan. Claims may be priced through the home plan via the local BCBS.

Inpatient Treatment

Any treatment where the patient does not go off-site following the procedure. For example, residential treatment or detox treatment occurs at a provider/facility and the patient does not leave the premises between procedures.

Itemized Claim

When a claim or UB-04 with more than one date of service specifically lists each date and the procedure completed on that date. For example, an itemized claim that includes a date range of 01/20/2016 - 01/22/2016 would specifically list each date (01/20/2016, 01/21/2016, and 01/22/2016) and the procedure completed on that specific day. Many insurers request itemized claims after the initial claim submission and it is generally used for outpatient treatment claims.

Local Payer

Most Blue Cross Blue Shield plans are not in the same state as the provider when treatment is received. Generally, claims need to be sent to the local BCBS (within the same state) to be processed correctly. If the claim needs to go to the home plan or a carve-out, the local BCBS will forward the claim or let the billing company know.

Managing Organization

The company or organization that is responsible for managing the claims, utilization, or VOB for an Organization.

Managing Organization Admin

Managing Org Admins are users with additional privileges to manage and customize your AveaOffice account. Managing Org Admins are able to work within the billing system but they may also do the following:

• Access all organizations within your managing organization
• Create new claim rules
• Access and edit all claim rules and settings
• Access and edit all top-level account configuration (queues, statuses, issues, default claim submission settings)
• Create Managing Organization Reports
• Add and manage Managing Organization Users, Organization Admins and Users, and Practice Admins and Users.
• Promote users to an Admin role

Member

Another name for the insured/covered party. The patient is not always the member. A member could be the patient’s parent, spouse, or sibling.

Name-Matching

An internal Avea Support Team process to ensure that every new payer, practice NPI, and rendering provider NPI is matched to a record in the clearinghouse for smooth claim processing.

NPI

National Provider Identifier is a number that each provider must have as mandated by HIPAA. Providers apply via state or federal government and they can take up to 30 days for approval and issuance. NPI’s are also applicable to the physicians who conduct and advise the treatment.

Organization

An Organization is a group that manages the practice(s).

Out of Network

When a provider does not have any contracts in place with a payer for certain procedures, that provider is considered to be out of network for those procedures. Out of network providers don’t normally get reimbursed by payers as highly as in-network providers, and all uncovered charges are the member's responsibility.

Outpatient Treatment

When a patient receives treatment at a facility but does not stay overnight for treatment. For example, a patient might have eight hours of therapy and rehabilitation treatment during the day, but goes home or off-site for the remainder of the day.

Patient/Member Responsibility

All deductible, co-pay, co-insurance, and non-covered charges that the member is obligated to pay per contract.

Payer

Another word for the insurance company. For example, Cigna is a “payer.”

Posting

When a claim has been processed, a member of the billing team will “post” the claim payment information into AveaOffice. Posting can be completed with an EOB or a Claim Summary.

POTF - “Proof Of Timely Filing"

Payers require claims to be filed within a certain time period. Normally, payers require claims to be filed within 90-180 days of the rendered service depending on the insurance company. 

Provider

Another name for the facility or organization administering the treatment.

Practice

A Practice is a location where multiple facilities might be in one physical location.

Present on Admission (POA) Indicator

Present on Admission is defined as being present at the time the order for inpatient admission occurs. The indicator is appended to the diagnoses code on claim forms.

• Y - Diagnosis was present at the time of inpatient admission.
• N - Diagnosis was not present at time of inpatient admission.
• U - Documentation insufficient to determine if the condition was present at the time of inpatient admission.
• W - Clinically undetermined. Provider was unable to clinically determine whether the condition was present at the time of inpatient admission.

Processing Events

The claim submission events from the clearinghouse during the claim-scrubbing process. 

Protected Trust

Protected Trust enables you to encrypt and email patient information other PHI from many practice management, EHR, and other applications in a secure, HIPAA-compliant manner.

Rack Rates

Rates that each provider negotiates and contracts with specific payers for certain procedures. For example, a provider might have a contract with Blue Cross Blue Shield for 0913 treatment where Blue Cross is contracted to pay $100 per each day of 0913 treatment. This does not mean that the provider bills the patient for only $100, they typically have their own rates which are higher than the contracted rate.

Residential Treatment

Treatment that occurs overnight at a residential treatment facility. The abbreviation for residential treatment is “RTC.”

Resubmits

When a claim has been withdrawn from the payer’s system incorrectly, we must resubmit the claim to the payer in order to have the payer re-enter said claim into their system. After the claim has been resubmitted, we can follow up with the payer regarding the claim status.

Revenue Code/Procedure Code

The four-digit identifier for a specific treatment. For example, the following are Behavioral Health Treatments/Services revenue code examples as extensions of 090X.

0911 - Rehabilitation
0912 - Partial hospitalization - less intensive
0913 - Partial hospitalization - intensive
0914 - Individual therapy
0915 - Group therapy
0916 - Family therapy
0917 - Biofeedback
0918 - Testing
0919 - Behavioral health treatments

Secondary/Tertiary Insurance

Many members have primary and secondary/tertiary insurance. These are additional policies that may cover procedures that the primary policy will not cover.

Service Rates

Service Rates allow users to manage single-case agreements and allow claims created with the designated service rates to balance correctly. To learn more about Service Rates, click here.

Single Case Agreements

Single Case Agreements, also known as SCAs, are contracts between an insurance company and an out-of-network provider. These types of contracts typically cover a specific client receiving a service for a designated amount of time at an agreed upon rate. These are handled in Avea using Service Rates. 

Treatment Episode

The patient's entire stay at the facility from admit to discharge, even when stepping down in levels of care.

UB-04

The official form we use for filing institutional/facility claims. These forms are submitted either electronically or paper via the clearinghouse.

Unsubmitted Attendance

Treatments that have been marked as attended but not created into claims yet.

VOB - Verification of Benefits

When a claim is denied for a “non-covered” procedure or “not a covered benefit,” we conduct a Verification of Benefits which includes deductible amounts/limits, co-pay/co-insurance amounts, and any other coverage items that are included in the member’s policy.