EDI Glossary
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
ADJUDICATION
The process through which claims are validated for eligibility, plan benefits and correct payment amount according to the provider's contract.
ALL-PAYER CLAIMS
Submission of all healthcare claims to WebMD through a single connection. This includes all commercial (Aetna, Cigna, Prudential, etc.), government (Medicare, Medicaid, Champus, Blue Cross Blue Shield) and paper claims.
ALLOWABLE CHARGE
The maximum fee that a health plan will reimburse a provider for a given service.
AMOUNT QUALIFIER CODE
Code to qualify amount.
APPEALS
The process used by a member to request the health plan re-consider a previous authorization or denial decision.
ASP
Application Service Provider, an entity that allows clients to tap into and use applications held on an off-site third-party server. This model allows the client to control the processing workflow while eliminating the need to purchase and maintain the application software.
ATTACHMENTS
Additional supporting documentation for processing or payment of medical or hospital claims. Examples may include office or progress notes, invoices, and medical records.
AUTHENTICATION
Confirmation of a user's identity, generally through username and password or biometric characteristics.
AUTHORIZATION
(Auth) approval required by the health plan prior to the completion of a procedure or visit
AUTHORIZATION NUMBER
Number assigned by health plan once procedure or visit requiring authorization is approved.
AUTHORIZATION OR CERTIFICATION INDICATOR
A yes/no indicator that identifies whether an authorization or certification is required per plan provisions.
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BATCH
When transactions are used in batch mode, they are typically grouped together in large quantities and processed en-masse. Typically, the results of a transaction that is processed in a batch mode would be completed for the next business day if it has been received by a predetermined cut off time.
BATCH CLAIMS
Claims that are combined into an electronic file and submitted for editing, formatting and distribution to insurance companies and TPO's either electronically or on paper.
BENCHMARKING
A performance measurement test, either within the organization (i.e. from year to year) or among organizations.
BENEFIT
Payments provided for covered services under the terms of the policy. The benefits may be paid to the insured, or on his behalf, to the medical provider. Benefit design includes the types of benefits offered and any applicable limits to those benefits, e.g., number of visits, percentage paid or dollar maximums applied, subscriber responsibility (cost sharing components), or subscriber incentives to use network providers.
BENEFIT AMOUNT
Benefit amount as qualified by the eligibility or benefits information and service type code.
BENEFIT COVERAGE
Code indicating which family members are provided coverage for this insured benefit.
BENEFIT COVERAGE RELATED ENTITY CITY NAME
The city name of the entity related to benefits described in the transaction.
BENEFIT DATE
Date or period associated with the eligibility or benefit being described.
BENEFIT PERCENT
Benefit percentage as qualified by the eligibility or benefit information and service type code.
BENEFIT PERIOD
The time period in which the insured or his dependents are eligible for coverage by the health plan.
BENEFIT QUANTITY
The number of visits or procedures allowed within a specific health plan.
BENEFIT RELATED ENTITY COMMUNICATION NUMBER
Communications number to contact the person, group or organization identified as the associated benefit related entity contact name.
BENEFIT RELATED ENTITY CONTACT NAME
The name of the benefit related entity to whom inquiries about the transaction may be directed.
BENEFIT RELATED ENTITY FIRST NAME
The first name of the person identified as the benefit related entity, or an individual subscriber or dependent.
BENEFIT RELATED ENTITY POSTAL ZONE OR ZIP CODE
The postal zone or ZIP Code of the entity associated with benefits described in the transaction.
BENEFIT RELATED ENTITY STATE CODE
The state postal code of the entity related to benefits described in the transaction.
BENEFIT STATUS
Benefit status of the individual or benefit related category to be further described in the transaction.
BILLING AGENCY
Organizations that perform the billing
BIOMETRICS
Electronic capture and analysis of biological characteristics, such as fingerprints, facial structure or patterns in the eye. Through advancements in smart cards and cheaper reader prices, biometrics is catching on as a security alternative to passwords.
BIRTH SEQUENCE NUMBER
A number indicating the order of birth for the identified person in relationship to family members with the same date of birth.
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CABLE MODEM
A modem that communicates over television cable instead of telephone lines. It can allow a continuously "live" connection to the Internet and transfer rates of about 1.5 Mbps, considerably faster than the 56 Kbps of a current computer modem or the 128 kbps of a digital subscriber line.
CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORM
A program administered both by the Department of Defense and the Veterans Administration that provides benefits for health care services furnished by civilian providers. Covers physicians and supplies to retired members of the uniformed (military) services and to spouses and children of active-duty, retired and deceased members.
CLAIM STATUS INQUIRY
A WebMD batch claim submitter can inquire at will on the status of claims in the adjudication process that have been sent by the provider to WebMD participating Payers.
CLAIMS SUBMISSION NUMBER
A number assigned by the federal government that identifies providers with WebMD and the insurance companies. The number may be either a federal tax identification number or a provider's social security number.
CO-PAYMENT (OR CO-PAY)
A way in which the enrollee shares in the cost of health care. The benefit plan requires the enrollee to pay a flat dollar amount per unit of service. An example of a co-pay might be $25. COBRA Consolidated Omnibus Budget Reconciliation Act: a federal law that requires most employers with 50 or more employees to provide the opportunity for continuation of coverage for members upon termination of employment as prescribed by current federal law.
COINSURANCE
An arrangement under which the insured person pays a fixed percentage of the cost of medical care after the deductible has been paid. For example, a health plan might pay 80% of the allowable charge, with the enrollee responsible for the remaining 20%; the 20% amount is then referred to as the coinsurance amount.
COINSURANCE MAXIMUM
This is the maximum dollar amount of Covered Expenses for which the Member is responsible in a Calendar Year. After that maximum is reached, this plan will pay 100% of Covered Expenses incurred during the remainder of that Calendar Year.
COMMERCIAL PAYER
Any non-governmental payer; a company in the business of selling insurance and paying insurance claims.
CONTRACT OR SUBSCRIBER CONTRACT
A legal agreement between an individual subscriber or an employer group and a health plan that describes the benefits and limitations of the coverage. One subscriber may have coverage under two contracts e.g., one for health and one for dental. Contract or Subscriber contract may also be referred to as Benefit Certificate or Certificate of Insurance, Evidence of Coverage, Health Benefit Contract or Policy.
CONVERSION OPTION
The exercise of an option to purchase individual coverage at a negotiated rate by a person who is leaving an employee group, typically at retirement.
COORDINATION OF BENEFITS (COB)
The provision that applies when an enrollee is covered by two health plans at the same time. The provision is designed so that the payments of both plans do not exceed 100% of the covered charges. The provision also designates the order in which the multiple health plans are to pay benefits. Under a COB provision, one plan is determined to be primary and its benefits are applied to the claim first. The unpaid balance is usually paid by the secondary plan to the limit of its responsibility. Benefits are thus "coordinated" between the two health plans.
COVERAGE LEVEL
Code indicating the level of coverage being provided for this service.
COVERED SERVICES
Hospital, medical, and other health care services incurred by the enrollee that are entitled to a payment of benefits under a health benefit contract. The term defines the type and amount of expense, which will be considered in the calculation of benefits.
CURRENT PROCEDURAL TERMINOLOGY CODE (CPT4)
This code is published by the American Medical Association (AMA) and is used to indicate the procedures or tests performed in conjunction with a diagnosis. These codes are required on claims and encounters.
CUSTODIAL CARE
Care that is provided primarily to meet the personal needs of the patient. Such care includes help in walking, bathing or dressing. It also includes preparing food or special diets, feeding, administering medicine, or any other care, that does not require continuing services of skilled medical personnel, i.e. a Registered Nurse.
CUSTOMARY AND REASONABLE (C&R)
The amount customarily charged for the service by other physicians in the area (often defined as a specific percentile of all charges in the community), and the reasonable cost of services for a given patient after medical review of the case. Also called "Usual, Customary and Reasonable" (UCR).
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DEDUCTIBLE
An amount the insured person must pay for covered services during a calendar year, January 1 through December 31, before health benefit payments begin.
DENIED CLAIM
A submitted claim processed and adjudicated by an insurance payer, resulting in $0.00 payment as noted on the remittance advice.
DEPENDENT
Person (spouse or child) other than the subscribing member who is covered under the subscriber's evidence of coverage or benefit certificate. May also be referred to simply as "Member" or "Beneficiary".
DIGITAL CERTIFICATE
Also called a digital ID. An official electronic identity document based on public/private key encryption and obtained through a certificate authority. Includes a user's name and registered serial number as well as the user's public key and its expiration date. Most certificates conform to the International Telecommunication Union's X.509 standard, but not all are compatible across all Web browsers.
DIGITAL SUBSCRIBER LINE
A new digital phone connection envisioned as a solution to the limited speed of analog telephone lines. More than five times faster than an ISDN (see definition below), a DSL skips the analog-digital-analog conversions and sends data directly in digital format. Signal splitting also will allow simultaneous voice and data communication on the same line. DOB The date of birth of the health plan member or dependent.
DRUG FORMULARY OR RECOMMENDED DRUG LIST (RDL)
A list of preferred pharmaceutical products that health plans, working with pharmacists and physicians, have developed to encourage greater efficiency in the dispensing of prescription drugs without sacrificing quality.
DURABLE MEDICAL EQUIPMENT (DME)
Mechanical devices, equipment and supplies, which enable a person to maintain functional ability. Also called Medical Equipment.
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E-BUSINESS, E-COMMERCE
An overarching term for service, sales and collaborative business conducted electronically, most often over the Internet, either business-to-consumer or business-to-business. Some define e-commerce as a monetary transaction segment of e-business but in most cases, the terms are synonymous.
E-HEALTH
Both a concept and a business strategy, e-health empowers users by bringing health information, products and services online. Portals and niche sites can include everything from consumer health content, health plan descriptions and insurance quotes to ask-a-doctor messaging. Some sites, such as online pharmacies, cross over into e-business or e-commerce.
EDI (Electronic Data Interchange)
Information /data passed from one computer to another.
EFFECTIVE DATE
The date at which the member or dependent's coverage becomes active and they are entitled to receive the benefits provided under the Plan.
ELECTRONIC EXPLANATION OF BENEFITS (EEOB or EOB)
The statement that comes back electronically, explaining each component of a submitted claim, (what was paid, how much and any reason for non-payment).
ELIGIBILITY
A service used to verify patient eligibility and benefit coverage online
ELIGIBILITY DATES
Date or period associated with the eligibility or benefit being described.
EMR (ELECTRONIC MEDICAL RECORD)
Also called computer-based patient record (CPR) or patient health record. An EMR is much more than a computerized medical chart, but rather serves as a "personal health library" providing access to all resources on a patient's health history, including insurance information. An integrated EMR will link to separate sources detailing medical history and images, laboratory results and drug allergies. Several organizations are focused on creating standards for EMRs, including common coding terminology, clinical decision support, patient confidentiality and secure data transfers.
ENCOUNTER
A record describing services rendered to a patient.
ENROLLEE
An individual who is enrolled and eligible for coverage under a health plan contract. This term encompasses both the subscriber and any of his/her covered dependents, each of whom may also be referred to as a "Member".
ENROLLMENT
The process of enrolling providers with insurance companies that require an EMC (Electronic Medical Claim) agreement to send transactions electronically.
ERA
Electronic Remittance Advice (ERA) informs service providers of the fiscal amount an insurance carrier will pay on a specific claim, including the amount to be paid for each particular service listed on a claim.
ETHERNET
A popular method for sending data through a local area network using a single-channel cable and a special data collision protocol to detect network availability
EXCLUSIONS
Specific conditions or circumstances that are not covered under the health plan benefit agreement. It is very important to consult the health plan benefit agreement (may also be called the Evidence of Coverage, Certificate, or Subscriber Contract) to understand what services are not covered benefits.
EXPLANATION OF BENEFITS (EOB)
A form sent to the enrollee after a claim for payment has been processed by the health plan. The form explains the action taken on that claim, including the amount paid, the benefits available, reasons for denying payment, and the claims appeal process.
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FISCAL INTERMEDIARY
Under the Medicare program, a third-party processor, usually paid by the government agency, held responsible for adjudicating and paying claims to providers and recipients
FTP
File Transfer Protocol a technical communication method for sending electronic transactions.
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GROUP NUMBER
The number assigned by an insurance payer to associate a member with the member's employer.
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HCFA (Health Care Financial Administration)
The Federal agency that oversees health care, including the Medicare and Medicaid programs. HCFA 1500 A professional/medical claim. Also known as a CMS 1500.
HEALTH BENEFIT PLAN
The plan described and is defined in the health plan benefit contract (may also be referred to as Evidence of Coverage, Subscriber Contract or Certificate), which delineates the set of covered health care services and benefits offered, and the health care provider network available to the member
HEALTH INSURANCE ASSOCIATION OF AMERICA (HIAA)
A national trade association representing U .S. private health insurance companies.
HEALTH MAINTENANCE ORGANIZATION (HMO)
A type of health care plan under which the enrollees receive all the medical services under a Health Benefit Plan through a specific group of participating doctors and hospitals.
HELP DESK
WebMD 's team that provides support for production client issues.
HIPAA
Health Insurance Portability and Accountability Act (HIPAA) Improves efficiency and effectiveness or health care systems by standardizing the electronic exchange of administrative and financial data. Protect security and privacy of transmitted information.
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ICD-9 CODE
International Classification or Diseases
ID CARD / IDENTIFICATION CARD
A card issued to a subscriber and possibly his/her dependents, which allows the subscriber to identify himself or his covered dependents to a provider for health care services. The card is often used by the provider to determine patient eligibility, benefit levels and to prepare the billing statement.
IMMUNIZATIONS
Injections recommended by guidelines published by the Advisory Committee on Immunization Practices (ACIP) of the U.S. Public Health Service or the American Academy of Pediatrics (AAP) designed to prevent diseases.
IMPLEMENTATION
The process through which a product or service is enabled for a provider, often in concert with a Physician Office Management Information System (POMIS) vendor.
IN-NETWORK
Refers to the use of providers who participate in the health plan's provider network. Use of an out-of -network provider often results in additional expense for the enrollee.
INDEMNITY
A traditional health insurance plan that reimburses for medical services provided to patients based on bills submitted after the services are rendered. Also know as fee-for-service plans. These plans generally do not have a specific provider network.
INFORMATION RECEIVER
Entity who is asking the questions in an Eligibility or Benefit transaction, typically the medical service provider.
INSURANCE TYPE
Code identifying the type of insurance policy within a specific insurance program.
ISDN (INTEGRATED SERVICES DIGITAL NETWORK)
A digital communications route capable of transmitting text, graphics, video and audio at about 64K-128K bps. Although an ISDN line is slower than a fiber distributed data interface, it's faster than a standard telephone line and is a popular way to connect local area networks.
ISP (INTEGRATED SERVICE PROVIDER)
A company that provides modem or network users with access to the Internet and the World Wide Web. Some charge by the hour, but most offer monthly or yearly flat rates. Recently, some telephone companies have become ISPs, offering Internet access combined with local telephone service.
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LAN (LOCAL AREA NETWORK)
A network of computer and peripherals in close proximity, usually in the same building. A LAN can facilitate high-speed exchange of text, audio and video data among hundreds of terminals.
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MANAGED CARE
A type of health insurance policy that uses selective provider contracting to have patients seen by a network of contracted providers in an effort to reduce costs and improve quality of care. Certain services under managed care require pre-authorization by the health plan.
MEDICALLY NECESSARY
Services or supplies provided by a licensed health facility or health professional, which are determined by the health plan company and it's contracting or employed Physician Group to be: Not Experimental or Investigational. Appropriate and necessary for the symptoms, diagnosis, or treatment of a condition, illness or injury. Provided for the diagnosis or care and treatment of the condition, illness, or injury. Not primarily for the convenience of the Member the Member's Physician, or anyone. The most appropriate supply or level of service that can safely be provided. For example, outpatient rather than inpatient surgery may be authorized when the setting is safe and adequate.
MEDICARE CROSSOVER
Claims submitted directly to Medicare which will be automatically forwarded to the secondary commercial payer for additional processing and applicable payment. Most insurance payers require that an employer group and its members be set up in the payer's systems if this benefit is offered. Not all commercial payers accept Medicare crossover claims.
MEMBER
An individual or dependent that is enrolled in and covered by a managed health care plan. Also called Enrollee or Beneficiary.
MEMBER ID
This is the unique number the payer or information source uses to identify the insured
MEMBER NAME
The patient name. The name can be either the subscriber or the dependant.
MODEM
A device used to communicate data over voice networks, which requires a phone line.
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NETWORK
The doctors, clinics, hospitals and other medical providers that a health plan contracts with to provide health care to its members. In a PPO or HMO, members are generally limited to network providers for full coverage of their health costs.
NETWORK PROVIDER
Physicians, hospitals or other providers of health care who have contracted with the health plan to participate in a specific network. Providers are listed in the Preferred Provider Directory given to each Member upon enrollment.
NON-PARTICIPATING PAYERS
A payer that does not participate, or participates very minimally in programs under which they bear the cost of electronic hea1thcare transactions. There is usually a charge to the provider because of additional set up and enrollment that is required for these payers. (ex. Medicaid or Medicare)
NON-PARTICIPATING PROVIDER
A medical provider who has not contracted with a health plan as a participating provider.
NSF (National Standard Format)
An industry standard for formatting claims.
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OCCUPATIONAL THERAPY
Treatment to restore a physically disabled person's ability to perform daily activities such as walking, eating, drinking, dressing, toileting, and bathing.
OUT OF NETWORK
The use of health care providers who have not contracted with the health plan to provide services. HMO members are generally not covered for out-of-network services except in emergency situations. Members enrolled in preferred provider organizations (PPO) and point-of-service (POS) plans can go out-of-network, but will pay some additional costs.
OUT-OF-POCKET MAXIMUM
Refers to the maximum amount that an enrollee will have to pay for expenses covered under the health plan. The maximum is a sum of all paid deductible and co-payment or coinsurance amounts.
OUTPATIENT
A patient who is receiving care at a hospital, physician office or other health facility without being admitted to the facility for an overnight stay. The term "ambulatory" is often used to describe outpatient care.
OUTPATIENT SURGERY
Surgical procedures performed that do not require an overnight stay in the hospital or ambulatory surgery facility. Such surgery can be performed in the hospital, a surgery center, or physician office.
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PACS (PICTURE ARCHIVING AND COMMUNICATIONS SYSTEM)
A costly system that uses an image server to exchange X-rays, CT scans and other medical images over a network. Mini-PACS' specialize in one type of image such as ultrasound.
PART A MEDICARE
A government-subsidized medical insurance program for older adults and disabled persons, covering services rendered by institutional providers such as hospitals, skilled nursing facilities, and home health agencies, to the aged.
PART B MEDICARE
A government-subsidized medical insurance program for older adults or disabled persons. Part B covers a portion (80 percent) of the cost of certain physician or professional services, outpatient physical therapy, X-rays, laboratory tests and other medical health care services.
PARTICIPATING PAYERS
A payer that chooses to participate fully in efforts to expand the volume of electronic healthcare transactions by bearing all or a significant proportion of the cost of such transactions. (i.e. Aetna, Cigna, Oxford, United. see full Payer list) http://www.webmdenvoy.com/pages/payers/lists.html
PARTICIPATING PROVIDER
A physician, hospital, pharmacy, laboratory, or other appropriately licensed facility or provider of health care services or supplies, that has entered into an agreement with a managed care entity to provide services or supplies to a patient enrolled in a health benefit plan.
PATIENT STATEMENTS
A written statement produced to articulate services rendered, charges billed to insurance and any remaining charges owed by the member.
PAYER ID
The identification number assigned to the payer by WebMD for electronic submission of data.
PAYER NAME
A field to provide the health plan name for the related data elements in the submission.
PAYER/CARRIER
Organization that pays providers for health care services rendered in accordance with a contract between the health plan and the member and the health plan and the provider. (ex. Insurance companies such as Aetna)
PAYMENT DATE
Date of payment PCP Primary Care Physician. Many managed care plans require selection of a primary care physician that serves as the "gatekeeper" of services rendered on behalf of the member or their dependents.
PDA (PERSONAL DIGITAL ASSISTANT)
A hand-held computer that provides access to notes, phone lists, schedules, and with additional connectivity, paging systems. PDAs have no hard drive and most lack keyboards. Using Windows CE or a proprietary operating system, input is predominantly pen-based, although speech recognition may become more prevalent.
PLAN NETWORK INDICATOR
A "Y" value indicates the benefits identified are considered In-Plan-Network. An "N" value indicates that the benefits identified are considered Out-Of-Plan-Network. A "U" value indicates it is unknown whether the benefits identified are part of the Plan Network.
POINT OF SERVICE (POS)
A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but typically requires enrollees to pay higher out-of-pocket fees for out of network providers.
POMIS
Physician Office Management Information System, the computer system in a physician's office that handles scheduling, financial data, and sometimes clinical information.
PORTAL
A Web site that acts as a doorway to a variety of other sites and services. Healthcare portals can guide high volumes of users to search engines, drug databases, consumer content, online prescription services, medical supplies, and physician continuing medical education.
PRACTICE MANAGEMENT SYSTEM
Software systems that provide an accounts receivable and scheduling system for providers. Patient statements, HCFA 1500s and UB92s are usually generated directly from the Practice Management System. (examples include: WebMD Practice Services (a.k.a. Medical Manager), Medisoft, Misys, IDX)
PRE-AUTHORIZATION
A procedure used to review and assess the medical necessity and appropriateness of certain types of hospital admissions and non-emergency outpatient services before the services are provided.
PRE-CERTIFICATION
Applies to specified services that require review and approval prior to the expense for such services being incurred. If a service is not Pre-Certified, benefits paid for that service would be reduced in accordance with the provisions of your Certificate of Insurance or Evidence of Coverage.
PRE-EXISTING CONDITION
A health condition (other than a pregnancy) or medical problem that was diagnosed or treated before enrollment in a new health plan or insurance policy. Some pre-existing conditions may have a waiting period attached to them or be excluded from coverage.
PREFERRED PROVIDER ORGANIZATION (PPO)
A type of health benefit plan designed to give enrollees incentives to use health care providers designated as "preferred providers", but that also give substantial coverage for services received from other health care providers. PPO plans can also be distinguished from HMO plans by the ability of PPO members to see any specialty physician without referral from a PCP, although some HMOs with a POS feature may allow this as well.
PRESCRIPTION
A written order or refill notice issued by a licensed medical profession for drugs that are only available through a pharmacy.
PREVENTIVE CARE
Office visits for the evaluation and management of the member's physical development for prevention of future medical problems.
PRIMARY CARE PHYSICIAN (PCP)
A doctor selected by the enrollee to be the first physician contacted for any medical problem. The doctor acts as the patient's regular physician and coordinates any other care the patient needs, such as a visit to a specialist or hospitalization.
PRINT IMAGE
Electronic format submitted to WebMD that looks like a printed claim in an electronic format.
PRIOR AUTHORIZATION
The process of obtaining advance approval before receiving certain health care services covered under a health plan.
PRO
Professional Review Organization
PROSTHETIC DEVICES
A device that replaces a part of the human body. These devices are necessary because a part of the body is permanently damaged, absent or is malfunctioning.
PROVIDER
A licensed health care facility, program, agency, physician or other health professional that delivers health care services.
PROVIDER ID
A unique number assigned to providers that authenticates their identity and validates that they are approved to submit claims to the health plan.
PROVIDER NETWORK
The set of providers.
PROVIDER SET UP FORM
A form required by WebMD that enables provider to be setup and enrolled in the appropriate WebMD systems. This form can be obtained from your Practice Management Vendor or WebMD.
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RADIATION THERAPY
Treatment of disease by x-ray, radium, cobalt or high-energy particle sources.
REAL-TIME / REAL-TIME INFORMATION SYSTEM
Requested transactions (e.g. eligibility, claims status) that receive an immediate response, most often accessing the payer's actual information system. Response times range from a couple of seconds to around thirty seconds, and should not exceed one minute.
REASONABLE AND CUSTOMARY
A charge that falls within the common range of services by a majority of providers for procedures in a given geographic region, or that is justified based on the complexity or the severity of the treatment.
REFERRAL
A referral transaction is used to submit referrals to other providers and then submitted to the patient's insurance carrier or managed care plan for approval and posting to the patient's file.
REJECTED CLAIM
A submitted claim that does not meet edit requirements requested by the payer. An electronic claim is usually rejected due to claim data that is missing or invalid. Rejected claims are returned to the provider with requests for missing information or correction of invalid information. Claim must be corrected and resubmitted for acceptance into the payer's system for processing.
ROSTERS
An Eligibility Roster is an electronic file containing coverage dates, demographics and benefits information for a group of related managed care plan members.
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SECOND OPINION
The voluntary or required visit to another physician or surgeon regarding diagnosis, prognosis and course of treatment.
SERVICE AREA
The geographic area in which a health plan is prepared to deliver health care through a contracted network of participating providers.
SERVICE TYPES
Code identifying the classification of service.
SEX
Code indicating the gender of the individual.
SITE ID
A unique ID used in conjunction with claims submission id to distribute reports separately to providers and/or locations (if needed).
SKELETAL ENROLLMENT
This type of enrollment is set up like an auto enrollment but special carrier requirements like sub IDs are filled in by WebMD.
SKILLED NURSING FACILITY (SNF)
A licensed institution (or a distinct part of a hospital) that is primarily engaged in providing continuous skilled nursing care and related services for patients who require medical care, nursing care or rehabilitation services.
SMART CARD
A portable, updatable card that can be used to store personal identification, medical history and insurance information. Because it has its own microprocessing chip, a smart card can store thousands more bits of information than a magnetic strip card, although it requires a special card-reading device.
SSN
Social Security Number. The social security number may not be used as a provider identification number for any federally administered programs such as Medicare.
SUBMITTER ID
A unique ID assigned by WebMD used to properly process transactions and distribute reports.
SUBMITTER
Any organization or provider that submits claims.
SUBSCRIBER
Person who can be uniquely identified to an information source, traditionally referred to as a member. The subscriber may or may not be the patient.
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T1, T3, T4
Types of transmission lines in the T-carrier telecommunications system. T1 lines can transmit about 1.5M bps of data. A T3 line contains 28 T1 lines together and can transmit about 45 times the data of a single T1, enough for full-motion video. Six T3 lines make one T4 line, capable of transmitting about 274 Mbps.
TELEMEDICINE
As a segment of telehealth, telemedicine focuses on the provider aspects of healthcare telecommunications, especially medical imaging technology.
TELERADIOLOGY
Conducting radiology image exchange and/or image interpretations electronically, usually via videoconferencing or messaging.
TESTING
WebMD provider level certification of claims format and data content.
TPA
Third Party Administrator that aggregates claims from multiple providers for submission from one source.
TRACER CLAIM
Automatic resubmission of claims previously submitted with no payment or response from the payer. Tracer claims are usually sent based on the billing cycle set up in your practice management system. All tracer claims should be submitted electronically instead of on paper. Most payers recommend waiting 45 days before sending the tracer claim to avoid duplicates in payer's system.
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UB92
A hospital/institutional claim.
UPIN
Universal Physician ID Number assigned by HCFA. The number will contain one (1) alpha plus five (5) numeric characters.
URGENT CARE
Services received for an unexpected illness or injury that is not life threatening but requires immediate outpatient medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering or sever pain, such as a high fever.
USUAL, CUSTOMARY AND REASONABLE
A "usual" charge is the amount that is most consistently charged by an individual physician for a given service. A "customary" charge is the amount that falls within a specified range of usual charges for a given service billed by most physicians with similar training and experience within a given geographic area. A "reasonable" charge is a charge that meets the Usual and Customary criteria, or is otherwise reasonable in light of the complexity of treatment of the particular case. Under an UCR Program, the payment is the lowest of the actual billed charge, the physician's usual charge or the area customary charge for any given covered service.
UTILIZATION MANAGEMENT
The entire group of systems designed to ensure members receive quality, medically necessary health care services at the appropriate level of care in a timely, effective, and cost efficient manner. It includes pre-certification, concurrent review, discharge planning, care management and retrospective review.
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WELL BABY / WELL CHILD CARE
Routine, preventative care, including testing, checkups and immunizations for a generally healthy child.
WELLNESS PROGRAM
A health management program that incorporates the components of disease prevention, medical self-care, and health promotion. It utilizes proven behavior techniques that focus on preventing illness and disability which respond positively to lifestyle related interventions.
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