RCM & DME billing glossary

The electronic remittance the payer returns to explain how a claim was paid or denied, including adjustments and patient responsibility. It can be auto-posted to the patient ledger.

The HIPAA electronic claim transaction. 837P is the professional version (mirrors the CMS-1500); 837I is the institutional version (mirrors the UB-04).

Independent certification that a supplier meets quality standards. Most DMEPOS suppliers must be accredited and meet surety-bond requirements to bill Medicare.

The payer's process of reviewing a submitted claim and deciding what to pay, adjust, or deny, based on the plan's rules and the patient's coverage.

Two federal laws that police improper financial relationships: the Anti-Kickback Statute bars paying for referrals in federal health programs, and the Stark Law restricts physician self-referral for certain services.

Payer and contractor reviews of claims and documentation. Clean orders, proof of delivery, and medical-necessity records are the best defense in an audit.

The HIPAA requirement to notify affected individuals, and the authorities, when unsecured protected health information is exposed. It is why access is scoped tightly and data is encrypted.

A required contract between a covered entity and a vendor that handles PHI on its behalf, binding the vendor to HIPAA safeguards. RCM partners sign one.

A widely used online profile where providers maintain credentialing data that commercial payers pull from, reducing repeated paperwork across plans.

Recording every billable service delivered so none is missed before the claim is built. Gaps here are silent revenue leaks that never reach a payer.

Automated and manual checks applied before submission to catch coding, eligibility, and formatting errors, so claims go out clean and are not rejected or denied.

A claim with no errors or missing information that can be processed and paid on the first submission without additional documentation or rework.

A service that receives claims from providers, checks them for errors, and routes them to the correct payers in the right format. It is the hub between a billing system and payers.

The standard paper claim form for professional (non-institutional) services billed by physicians, suppliers, and other individual providers. Its electronic equivalent is the 837P.

Verifying a provider's qualifications, licensure, and history so payers will recognize them. It is the gate to becoming an approved, billable provider.

Confirming a patient's active coverage, plan rules, deductible, and any prior-authorization needs before service, to prevent downstream denials.

The statement a payer sends explaining what it paid, adjusted, or denied on a claim, and what the patient may owe. The provider-facing electronic form is the 835/ERA.

The categories of improper billing that compliance programs are built to prevent and detect, from intentional fraud to avoidable waste and abusive practices.

The Health Insurance Portability and Accountability Act, the federal law setting privacy and security standards for protected health information.

The HIPAA principle that access to PHI is limited to the least information needed to do the job. It shapes role-based access in a compliant workflow.

A unique 10-digit identifier for a healthcare provider or organization, required on claims. Type 1 is for individuals; Type 2 is for organizations.

The federal office that investigates fraud, waste, and abuse in health programs and publishes compliance guidance. Its exclusion list is checked before hiring or contracting.

Recording each payer and patient payment against the correct claim and line, then reconciling it to the remittance. Accurate posting is what makes denials and underpayments visible.

The Provider Enrollment, Chain, and Ownership System, the online system used to enroll and manage provider and supplier records with Medicare.

Confirming a provider's credentials, such as license, education, and board status, directly with the issuing source rather than from a copy. It is the backbone of credentialing.

Individually identifiable health information protected under HIPAA. In electronic form it is ePHI, which carries specific security safeguards.

Registering a provider or supplier with a payer so claims can be submitted and paid. For Medicare this runs through PECOS.

The Provider Transaction Access Number, a Medicare-issued identifier tied to enrollment that links a provider to a specific contractor and location.

The periodic process of re-verifying enrollment information with a payer to keep billing privileges active. Missing a revalidation deadline can halt payments.

An itemized form listing the services, procedures, and diagnoses from a patient encounter. It is the source document the billing team turns into a claim.

A bond a DMEPOS supplier must maintain for each enrollment location to bill Medicare, protecting the program against improper payments.

A standardized code identifying a provider's type and specialty. It is used in enrollment and on claims to match the provider to the correct classification.

The deadline by which a claim must reach the payer, counted from the date of service. Missing it usually results in a non-appealable denial, so it is tracked closely.

The standard institutional claim form used by hospitals, home health agencies, and other facilities. Its electronic equivalent is the 837I.