Review-nursing glossary

The vocabulary of remote review work, in plain language.

Every review nurse, coder, and biller works in the same shared language - utilization management, prior authorization, denials, appeals, and the codes that explain them. These are the terms you will hear on day one, defined as neutral industry concepts. Commercial medical-necessity criteria sets are named only in the abstract; RemoteNurse teaches review reasoning with its own original synthetic framing, never proprietary criteria.

198 of 198 terms

Review workflow

Utilization managementUM: The payer-side process of reviewing whether a requested or delivered service is appropriate and covered. It spans prospective, concurrent, and retrospective review, and it is the umbrella most remote review-nurse roles sit under.
Prior authorizationPA: A payer's advance approval of a service before it is delivered. A reviewer checks the request against plan rules and medical-necessity guidance, then approves, pends for more information, or routes it for a coverage determination.
Prospective review: Review done before care is delivered, such as a prior authorization. The goal is to confirm the requested service is appropriate and supported before it happens.
Concurrent review: Review done while a patient is still receiving care, typically during an inpatient stay. The reviewer checks that the ongoing level of care remains supported by the current documentation.
Retrospective review: Review done after care has already been delivered, usually when no advance authorization was obtained. The reviewer evaluates the completed record against the applicable rules.
Peer-to-peerP2P: A conversation between the requesting clinician and the payer's physician reviewer when a case cannot be approved on documentation alone. Nurse reviewers prepare and route these; the coverage decision itself belongs to the physician reviewer.
Turnaround timeTAT: The time a reviewer has to complete a decision, set by regulation or plan policy. Missing a TAT deadline can itself change the outcome, so watching the clock is part of the workflow.
Level of care: The intensity of setting a patient's condition supports - for example inpatient, observation, or a lower-acuity setting. Matching documentation to the right level of care is a core concurrent-review task.
Medical necessity: The standard that a service is reasonable and appropriate for the patient's condition under the plan's rules. Reviewers assess whether the record supports it; they do not diagnose or direct treatment.
Discharge planning: Coordinating a safe next setting as an inpatient stay winds down. Review nurses flag when the documented plan and the record disagree so the gap can be resolved before discharge.
Medical-necessity criteria sets: Commercial guideline products (for example MCG or InterQual) that some payers license to structure medical-necessity review. They are proprietary to their publishers. RemoteNurse does not reproduce or paraphrase any proprietary criteria; it teaches review reasoning with its own original synthetic framing.
Utilization reviewUR: The act of reviewing a specific request or stay against plan rules and medical-necessity guidance. Utilization review is the work; utilization management is the programme it sits inside, so job titles use the two almost interchangeably.
Disposition: The next step a reviewer commits the case to at the end of a review: approve the routing, pend for information, escalate for a qualified determination, or hand it to the accountable owner. The Case Lab scores the disposition you pick, so read the options apart before choosing.
Pend: To hold a request open, without deciding it, while a named piece of missing evidence is chased. A pend says what is missing and who owes it. Holding a case with nothing outstanding is not a pend, it is a delay.
Escalation: Routing a case to someone with authority the reviewer does not have, most often a physician reviewer for a medical-necessity call. Escalating is not failing; it is the correct move whenever the decision sits outside your scope.
Electronic medical recordEMR: The clinical record system a hospital or practice documents in. A reviewer reads the record to find what was ordered, done, and written down; the record is evidence, not a decision.
Release of informationROI: The controlled process of disclosing a patient's records to an authorized requester. In this field ROI means release of information, never return on investment.
Clinical documentation integrityCDI: Work that checks whether the record says clearly what the care actually was, and queries the writer when it does not. A query asks for clarification; it never suggests an answer.
Chronic care managementCCM: Ongoing, non-face-to-face coordination for members with several long-term conditions, billed against time spent and documented care planning. The same three letters name the Certified Case Manager credential, so check which one a posting or a drill means.
Certified Case Manager: A case-management credential issued by the Commission for Case Manager Certification, held by many hospital and payer case managers. It is a credential, not a billed service, and it is unrelated to chronic care management despite sharing the letters CCM.
Remote patient monitoringRPM: Care that uses devices to send a member's readings to the care team between visits. Billing turns on the number of days transmitted and the time spent reviewing them.
Medication therapy managementMTM: A structured pharmacist-led review of everything a member takes, looking for interactions, gaps, and duplicate therapy. The reviewer records findings and routes them; prescribing stays with the prescriber.
Observation care: A defined set of short-term treatment and reassessment services ordered while it is decided whether a patient needs admission. A patient in observation is an outpatient, whatever the bed looks like.
Inpatient admission: The formal admission that makes a person an inpatient, under an order from a physician or other qualified practitioner furnished at or before the admission. The order, not the bed, sets the status.
Internal coverage criteria: Criteria a plan publishes itself where the governing rules leave a gap, drawn from current evidence. A support desk can name them and gather against them; applying them is the reviewer's act.
Physiologic data: The readings a monitoring device collects. A support desk sets up the collection, checks it is happening and records what it sees, and reads no meaning into a number.
Care plan: The single electronic plan a patient's care is created, revised and managed against. Two plans for one patient is a duplicate to collapse, not a second opinion.
Do-not-use list: A published list of shortenings, symbols and dose designations that have been misread in ways that harmed patients. Where a shortening is on one, the word is written out in full.
Admission order: The order that starts an inpatient stay, with its author and its timestamp. It is the anchor every other entry in a level-of-care packet is read against.
Addendum: New information added after a note was signed, dated and attributed to whoever added it. It never overwrites the original entry, so both readings stay visible.
Alert queue: The list of readings a device flagged, ordered so the one that has to move now is not buried under the ones that can wait. The desk orders and routes the alerts; it does not judge the readings.
Audio-only fallback: Carrying a remote visit on two-way live audio when a patient at home cannot use video or will not agree to it, recorded as its own modality. It is a modality with its own record line, not a lesser version of the video visit.
Calendar as the source of truth: The one calendar every booking is made in, so a slot exists in a single place rather than in three people's heads. A change agreed on a call is not a change until the slot moves.
Care management consent: The patient's agreement, taken and recorded before the service starts, to be enrolled in a monitoring or care management programme. No consent on the record means no month to bill and nothing to count.
Closed-loop referral: A referral that only counts as finished when the report comes back, not when it was sent. The row stays open until the consult report is filed against it.
Cold-read test: Handing a tracker row to someone who was not there and seeing whether they can act on it without asking you a question. A row that fails it is unfinished, however clear it looks to the person who wrote it.
Comprehensive care plan: The written plan for a patient's conditions that a care management month is worked against and measured by. The desk checks it exists and is current; the clinician writes it.
Copy-forward: Carrying a paragraph from an earlier note into a new one, which drags stale findings with it unless it is checked. Every carried paragraph is checked against today's findings before it stands.
Crisis line: The number a practice's written procedure names for a caller in distress, which the desk dials rather than deciding anything. Learn the one your employer permits you to name, and keep it one click away.
The five rights of delegation: The five checks a delegated task is tested against before it is handed over: the right task, the right circumstance, the right person, the right direction, and the right supervision. A task failing any one of the five goes back rather than forward.
Crisis routing: Moving a caller in distress to the named clinician or line the written procedure gives, without assessing them on the way. The desk supplies speed and a record, never a judgement.
Distant site: The place the practitioner is working from at the moment a remote service is delivered. It is one of the two places a telehealth record has to name.
Direct and indirect supervision: Whether the person accountable for delegated work has to be present while it happens, or is reachable and answerable for it without being in the room. Which one applies decides whether the work may happen at all today.
Discharge summary: The closing document of a stay, which the transitions desk works the follow-up from. It names the medications, the follow-up and the pending results the desk works from.
Face-to-face encounter: The documented meeting with a practitioner that has to sit behind certain orders, inside its own window. The date and the author are what a reviewer checks first.
Gap list: The plan's list of members a measure says are still missing something, which the desk works row by row. It is a claim built from a rule, so every row is read against that rule before it is worked.
General supervision: Supervision where the accountable practitioner directs the work and stays answerable for it without being present while it is done. The practitioner stays answerable without standing in the room.
Independent contractor status: Working for a client under a contract rather than as an employee, carrying your own hours, equipment and tax filing. It changes who owns your hours, your equipment and your filing.
Initiating visit: The visit that starts a care management or monitoring service and puts the enrolment on the record. Without it on the record the enrolment has no start date.
Intake sweep: The scheduled pass across every channel that turns phone, portal, fax, email and post into one list. Sweep first, work second, so nothing is worked before everything is seen.
Interactive communication: A two-way exchange with the patient or carer, live rather than a message left, that a monitoring month can count. A message left is not interactive, however carefully it was worded.
Interactive telecommunications system: Equipment that carries two-way, live communication between a patient and a practitioner, with audio and video at the least. A phone call and a recorded message are not one.
Interactive contact: A live two-way contact with the patient or carer after a discharge, counted from the discharge rather than from the referral. Count it from the discharge date, not from the day the referral arrived.
Interdisciplinary group: The team that owns a hospice patient's plan, which the desk routes to rather than answers for. The desk routes to the group and never answers for it.
Late entry: A note written after the event it describes, which has to say on its face that it is late. It says on its face when it was written and when the event happened.
Mobile crisis: A community team that comes out to a person in crisis, kept on the record beside the local emergency number. A remote desk cannot dial a caller's town, so the numbers are gathered before the visit.
Monitoring device supply: Handing the patient the device and setting it up, as a step with its own record separate from the readings it later sends. It is its own dated step, separate from the readings that follow.
No-show list: The list of patients who missed a booked slot, worked to a close of rebooked, declined or routed. Every row closes as rebooked, declined or routed.
Non-leading query: A question to the author of a note that asks what the record supports without suggesting the answer. It asks what the record supports and offers no answer to agree with.
Originating site: The place the patient is sitting at the moment a remote service is delivered, which both the schedule and the visit record have to name. Confirm it on the day, because people move.
Plan of care: The signed plan an agency works to, which the desk checks for orders and signatures rather than for clinical content. The desk checks orders and signatures, never the clinical content.
Post-discharge visit window: The period after a discharge inside which the follow-up visit has to happen for the transition to count. Miss the window and the transition no longer counts, however good the call was.
Problem list: The running list of a patient's conditions in the chart, carrying a fact with no date and no doer. It shows that something is known, never that it happened at this visit.
Pull date: The day the sender ran an extract, which is not the day the file reached you. A file pulled in March answers nothing that happened after March, so both dates are recorded and labelled.
Qualified interpreter: An interpreter the practice supplies at no cost to the patient, offered instead of leaning on whoever came with them. Offer it rather than waiting to be asked.
Quality measure: A question about a named group of people and how many of them had a thing happen. A record answers it in two ways only: the thing happened, or a named reason says the person should never have been counted.
Recall list: The list of patients due to come back, worked forward into open slots rather than chased at random. Work it forward into open slots rather than chasing at random.
Referral order: The order that sends a patient on to another provider, carrying who ordered it and what is being asked for. It names who ordered it and what is being asked for.
Scope creep: Work that grows past the agreement one small favour at a time, until the hours no longer match the fee. Name it early in writing, while it is still one small favour.
Setting hand-off: The named pass of a patient from one care setting to another, with an owner on each side. Both sides have an owner, or the patient is between two desks.
Shared tracker: The queue a whole desk works from, written so a colleague who was not there can pick up any row cold. Every row carries an owner and a next-action date, even when the owner is you and the date is today.
Signature attestation: The statement that names the author of an entry and the time it was signed, so the record has an owner. An entry with no named author has no owner to ask.
Speed test: A measurement of the real upload and download speed on the connection you would work from. Run it at your working hours, because that is the hour the agency's floor is about.
Statement of work: The part of a client agreement that names the tasks, the hours and what is handed back, so the scope is written down before anyone argues about it. It is where the scope is written down before the work starts.
Structured hand-off: Passing a patient to a clinician in a fixed shape, so the receiver gets the same fields every time. The receiver gets the same fields every time, which is what makes it fast.
Teach-back: Asking the person to say back what they will do, so understanding is checked rather than assumed. A nod is not a plan, so ask for the words back.
Telehealth informed consent: The patient's recorded agreement to be seen remotely, taken before the room opens and written into the visit record. Consent on file with no date and no name tells the next reader nothing.
Transmitting day: A day on which a monitoring device actually sent a reading, counted rather than remembered. It is counted from the device record, never estimated.
Trigger list: The words and situations your employer's written procedure says start a transfer, learned before the first shift because you cannot look them up mid-call. The trigger fires on the words, not on the tone.
Unique tracking number: The number a review body returns on a submission, which every later message about that case is filed under. Every later message about the case is filed under it.
Unowned vendor mail: Vendor and payer post that lands on a shared desk with no named owner, and sits unread until somebody assigns it. Give it an owner at the sweep, or it sits unread until it is late.

Regulatory

Two-Midnight rule: A Medicare guideline that generally expects an inpatient admission when a physician reasonably expects the patient to need care spanning two midnights. It commonly drives the observation-versus-inpatient question in concurrent review.
Observation versus inpatient: The status distinction between a shorter observation stay and a full inpatient admission. The two carry different coverage and billing consequences, so the supporting documentation has to match the status assigned.
Prior-authorization clock: The regulated deadline for a prior-authorization decision. Expedited requests generally allow about 72 hours and standard requests about 7 days, though exact windows vary by program and plan - always confirm the rule that applies.
Expedited review: A faster review track used when waiting the standard timeframe could seriously jeopardize the patient. It shortens the turnaround-time window, so the clock is tighter.
Organization determination: A Medicare Advantage plan's decision on whether it will cover, and how much it will pay for, a requested item or service. Standard and expedited requests run on different clocks, set by different sections of the rules, so the two are never quoted together.
Adverse determination: A decision not to authorize or pay for a requested service, in whole or in part. Program rules reserve an adverse medical-necessity determination for a physician or other qualified reviewer, which is why a review nurse gathers and documents the evidence but never writes the denial.
Grievance: A member complaint about the quality or handling of care or service, distinct from an appeal of a specific coverage decision. Plans log and respond to grievances under their own timelines.
External review: An independent review of a denial by an outside organization after internal appeals are exhausted. It moves the final call outside the plan that issued the denial.
Healthcare Effectiveness Data and Information SetHEDIS: A widely used set of quality measures plans report on, covering things like screening and follow-up rates. Care-gap work is usually measured against it.
Health Insurance Portability and Accountability ActHIPAA: The federal law that sets the rules for using and disclosing protected health information. Its minimum-necessary principle is why a reviewer requests the specific record needed, not the whole chart.
Centers for Medicare & Medicaid ServicesCMS: The federal agency that runs Medicare and sets the federal rules Medicaid and Medicare Advantage plans work under. Its manuals and regulations are the source most review lessons cite.
Provider enrollment: Registering a provider with a payer so the payer will recognise and pay that provider's claims. It is a separate record from the provider's identifier, and one does not prove the other.
Revalidation: The periodic re-submission of an enrollment record a payer runs on a cycle. The payer starts the clock and sends the notice; a desk keeps the packet gathered so the notice starts work rather than panic.
Billing privileges: The permission to bill a payer for a provider's services. Enrollment grants it, and a lapse in enrollment stops it, whatever the provider is doing clinically.
Deactivation: An enrollment switched off, most often for inactivity or a missed deadline. Billing stops until it is reactivated, and reactivation is a filing rather than an appeal.
Revocation: An enrollment ended by the payer for cause. It bars billing and carries a bar on re-enrolling for a stated period, which is what separates it from a deactivation.
Primary source verification: Confirming a credential with the body that issued it rather than accepting a copy the provider supplied. The file keeps the source, the date of the check and what came back.
Managing employee: A general manager, business manager, administrator or director who exercises operational or managerial control over a provider. Enrollment and exclusion screening reach these people, not only clinicians.
Attestation: A provider's signature confirming that a profile or an application still says what is true. It is repeated on a cadence, and a profile left unsigned goes stale rather than being refused.
Check digit: The last position of a provider identifier, computed from the digits before it so that a mistyped number fails on sight. Nothing else in the identifier carries meaning.
Ownership disclosure: The set of application questions about who owns and controls a provider. A support desk checks that every question has an answer, and leaves what an answer means to compliance and counsel.
Minimum necessary: The rule that only as much health information as the stated purpose needs may be used or shared. Naming the purpose first is what makes the rule checkable.
Business associate: An outside person or firm that handles protected health information on a covered entity's behalf, under a contract that binds them to the same safeguards.
Privacy Rule: The HIPAA rule governing how protected health information may be used and shared, and the rights a patient has over it. It is the rule most daily desk decisions turn on.
Security Rule: The HIPAA rule governing the safeguards around electronic protected health information: the workstation, the connection, the screen and who can see it.
Breach notification: The duty to tell the people affected, and the regulator, when protected health information is exposed. What a desk owes in the first hour is a report upward, not an investigation.
Protected health informationPHI: Individually identifiable health information held or moved by a covered entity or a business associate. It is the thing every rule on this desk is protecting.
Part 2: The federal rule giving records of substance use disorder treatment protection beyond HIPAA. A release that satisfies HIPAA can still be refused under it.
Accounting of disclosures: The list a patient may ask for of where their information went, which only exists if the log was kept. Keep the log as the disclosure goes out, because it cannot be reconstructed later.
Amendment request: A patient's written request to change something in their record, which is answered either way in writing. Answer it in writing either way, inside the window the rule sets.
Audit log: The system's own record of who opened, changed or printed a record, and when. It is the evidence behind an access complaint, so it is read rather than remembered.
Business associate agreement: The written contract a practice signs with a vendor that will handle protected health information for it, fixing what the vendor may do with that information and what it owes back. No protected information moves to a vendor before it is signed.
Designated record set: The group of records a provider uses to make decisions about a patient, which is what a request for access reaches. It sets what a request for access actually reaches.
Electronic health information: Electronic protected health information held in the set a request for access can reach. Withholding it needs a named exception, not a habit.
Foreign status declaration: The form a contractor outside the United States gives a US client to declare that status for withholding purposes. The client keeps it on file; it is paperwork, not tax advice.
Information blocking: A practice that interferes with the lawful access, exchange or use of electronic health information. Delay counts as interference, so a slow answer is not a safe one.
Information blocking exception: A named condition under which withholding or delaying information is not blocking, which has to be met rather than assumed. An exception has to be met and documented, not assumed.
Measurement year: The year the care happened, which a later reporting year is scored on. Two years are open at once, so a row is placed against the measurement year before it is chased.
Mental health parity: The rule that a plan may not put heavier limits on behavioral care than it puts on medical care. A tighter behavioral limit is worth one question to the plan, in writing.
Permitted use: What a sender's own agreement says a file may be used for, written down before a value from it is loaded. Data that arrived for one purpose does not become usable for another by sitting in a folder.
Personal representative: Someone with authority to act for a patient, who is treated as the patient for the request in front of you. Treat them as the patient for the request in front of you, once the authority is checked.
Psychotherapy notes: A therapist's own session notes, kept apart from the rest of the chart and released only on a separate written authorization. A practice may never make that authorization a condition of treatment.
Purpose section: The part of a release form that says what the information may be used for, which fails more often than the signature. Read it first, and never stretch it to a different question.
Record retrieval filter: The date range, encounter or document type a retrieval is narrowed to, so only what was asked for comes back. Narrow it before you pull, so only what was asked for comes back.
Redisclosure notice: The notice that travels with released records saying the receiver may not pass them on further. It travels with the records, so it is attached rather than mentioned.
Right to revoke: The patient's right to withdraw a consent in writing, which the form itself has to state along with how to do it. A consent that does not carry it is not complete.
Specific and meaningful description: The element of a written consent that says exactly what information may be disclosed. All records is not one, and a consent that lacks it stops the disclosure.

Claims & billing

Claim: A provider's request to a payer for payment for services delivered. The claim carries the codes, dates, and charges the payer adjudicates against the member's benefits.
Denial: A payer's decision not to pay a claim, in full or in part. A denial arrives with reason codes that explain why and point toward what a resubmission or appeal would need to address.
Appeal: A formal request to reconsider a denial. A first-level (Level 1) appeal goes back to the payer; a second-level (Level 2) appeal escalates within the plan or to an independent reviewer, depending on the program.
Claim adjustment reason codeCARC: A standardized code on a remittance that explains why a claim's payment was adjusted or reduced. Reading CARCs correctly is how a biller learns what a denial actually turned on.
Remittance advice remark codeRARC: A supplemental code that adds detail to a CARC on a remittance, clarifying the adjustment further. CARCs and RARCs are read together to reconstruct a payer's reasoning.
Explanation of benefitsEOB: The member-facing statement showing how a claim was processed - what was billed, allowed, paid, and left to the member. It is a notice, not a bill.
835 remittance advice835: The electronic remittance transaction a payer sends a provider to report claim payment and adjustment detail. It is the machine-readable counterpart to the paper remittance a biller reconciles against.
Clean claim: A claim submitted with complete, correct information that can be adjudicated without needing more from the provider. Clean claims move faster and deny less often.
Place of servicePOS: The two-digit code naming where a service was delivered - for example an office, an outpatient hospital department, or the home. An authorization approved for one place of service does not automatically cover another.
Revenue cycle managementRCM: The end-to-end handling of a claim, from registration and eligibility through coding, submission, remittance, and appeal. Review, billing, and coding roles all sit somewhere on this cycle.
278 health care services review278: The electronic transaction that carries a prior-authorization or referral request and the payer's reply. Its certification-action codes A1 through A6 report the outcome - for example A4 means the request is pended because more information is required.
National Provider IdentifierNPI: The ten-digit number that identifies a provider on claims and authorization requests. A mismatched NPI is a common reason a request is returned before anyone reads the clinical detail.
Alphabetic index: The half of the diagnosis code book searched by the term the record uses. It points at a code rather than finishing one, which is why the entry it returns is a lead and not an answer.
Tabular list: The structured half of the diagnosis code book, arranged in chapters. A code is confirmed here, and the notes printed around it are the instructions a coder reads before reporting it.
Seventh character: The character some diagnosis categories call for in the seventh position of a code. Where a category uses one, a code that reaches a desk without it is treated as incomplete.
Placeholder character: The X the diagnosis code book puts in an empty character position, so that a seventh character still lands in the seventh position rather than wherever the shorter code ended.
Excludes1: A code book note meaning not coded here. It marks a code that is not reported alongside the code the note sits under, because the two conditions are not held to occur together.
Excludes2: A code book note meaning not included here. The excluded condition is not part of the code above the note, and a patient may carry both, so both codes can be reported where the record supports each.
Unspecified code: A code reported when the record does not carry the detail a more specific code would need. The coding guidelines describe these as acceptable, and sometimes necessary, reporting rather than as a defect.
Code assignment: Choosing the code that goes on a line. It sits with the person an employer delegates it to, which is what separates a coding support desk from the coder it routes questions to.
Amendment: A change made to a record after the fact. Guidance on late entries turns on whether the date, the author and the change itself stay visible rather than replacing what was there.
International Classification of Diseases, Clinical ModificationICD-10-CM: The diagnosis code set used on United States claims. It says what the condition is; procedure and service codes say what was done about it.
Corrected claim: A claim resubmitted to fix something the biller got wrong, rather than to argue with a decision the payer made. Sending an appeal where a corrected claim was needed loses time on both routes.
Redetermination: The first level of appeal after a denial, filed inside a stated window with the contents the rule names. It is decided by the payer's own contractor, not by an outside reviewer.
Reconsideration: The appeal level after a redetermination, decided by an independent reviewer. The record closes at this level, which is why everything the case relies on has to be in the packet.
Timely filing: The deadline by which a claim or an appeal has to reach the payer. It is a wall rather than a target: past it, the merits of the case stop mattering.
Ageing bucket: The band a receivable falls into by how long it has been outstanding. Each band asks for different work, so the bucket decides the action before anyone reads the claim.
Group code: The code on a remittance line that says who owns the balance after an adjustment: the payer, the provider, or the patient. It is read before the reason code, because it decides who is billed next.
Accounts receivableAR: The money billed and not yet collected, worked as a queue rather than a ledger. An AR desk chases claims by age, by payer and by denial reason.
Reference number: The number a payer gives for a call or a submission. It is the only proof the contact happened, which is why a call that ends without one is unfinished work.
Contact log: The line written after every outside contact: the date, the person, the reference number, what was said and what happens next. It is the record a colleague picks the work up from.
End-of-day report: The short written handover a desk leaves at the end of a shift: what was finished, what is pending, what is blocked and what expires next.
Parked exception: An item pulled out of a batch and left with the missing fact named, the owner named and a date on it. Parking keeps the batch moving; skipping leaves the item exactly as it was found.
Additional documentation request: A reviewer's written request for the records behind a paid claim, with a clock the desk works to. Treat it as a dated queue item with an owner, not as post.
Condition of payment: A requirement that has to be met before a claim can be paid, as opposed to guidance a payer merely prefers. Missing one is a hard stop, not a preference to argue about.
Good faith estimate: A written estimate of expected charges given to a patient before care, which the desk assembles and never turns into a promise. It is a written estimate, and the desk never turns it into a promise.
Incident-to billing: Billing staff work under a practitioner's own claim, which only holds when the supervision and the record behind it hold. It holds only when the supervision and the record behind it hold.
Ordering and referring provider: The practitioner named on an order or referral, whose enrolment record has to hold for the claim behind it to. An enrolment gap on that provider stops the claim behind the order.
Pre-service claim: A request for approval made before care, which carries its own clock and its own appeal route. It carries its own clock and its own appeal route.
Provisional affirmation: A pre-service decision that a request looks payable on what was sent, which still leaves the claim to be judged later. It is a look-ahead, not a payment, and the claim is still judged later.
Reconciliation: Checking two counts against each other and naming the difference instead of absorbing it. Rows at the start, minus rows closed, minus rows handed back, equals rows still open.
Risk adjustment: The data a plan reports about its members' diagnoses, which changes what the plan is paid. A reported diagnosis has to sit in a medical record from a qualifying encounter, or the record does not hold it.

Coverage & eligibility

271 eligibility response271: The electronic reply to a benefits inquiry, confirming a member's coverage and cost-sharing details. Checking the 271 before work is authorized prevents avoidable downstream denials.
Eligibility: Whether a member is actively covered under a plan on the date of service. Eligibility is the first thing a reviewer or biller confirms before anything else in the record matters.
Medicare AdvantageMA: Medicare coverage delivered by a private plan under contract to CMS. The plan runs its own prior authorization and issues organization determinations, so most remote review work on a Medicare member sits under Medicare Advantage rules rather than original Medicare.
Self-funded plan: An employer plan that pays claims from its own money and hires an administrator to run them. Because it is governed by federal ERISA rules rather than state insurance law, the appeal route and the deadlines differ from a fully insured plan covering the same service.
Advance beneficiary noticeABN: A written notice given to a Medicare patient before a service that Medicare is likely not to cover, so the patient can decide whether to accept the cost. Without a valid notice on file the provider usually cannot bill the patient for the denied service.
Coordination of benefitsCOB: The rules that decide which plan pays first when a member has more than one. Getting the order right is a common source of, and fix for, avoidable denials.
Coverage determination: The plan's formal decision about whether a specific service is covered for a member. Nurse reviewers assemble and document the record that supports the decision; the determination itself follows the plan's process.
Formulary: The list of drugs a plan covers, often with tiers and prior-authorization requirements. A medication prior authorization is checked against the formulary and its rules.
Cost share: What the patient owes for a covered service, as a copayment, coinsurance or deductible. A support desk quotes it from the plan's own record and never as a promise.
Exception request: A request that a plan cover a drug it excludes, or cover it on better terms. It cannot be decided without the prescriber's written reasons, so chasing that statement is the work.
Supporting statement: The prescriber's written reasons behind an exception request. Without it the plan has nothing to decide on, and the request sits still however complete the rest of the file looks.
National Drug CodeNDC: The identifier that names a drug product by labeler, product and package, so a claim line says exactly what was dispensed rather than what was meant.
Package code: The last segment of a National Drug Code. It states the size and form of the package rather than the drug, and it is the segment a claim line most often gets wrong.
Prescribing information: The label a manufacturer submits to the regulator, written for practitioners. A support desk takes the name, the strength and the form from it and reads nothing further into it.
Prescription number: The number a pharmacy files a prescription under. It is the handle a callback is picked up by, so it belongs in every refill log line.
Refill: A repeat supply on an existing prescription. Whether one is left is a fact on the authorization, and issuing a new one is a prescriber's act rather than a desk's.
Controlled substance: A drug placed in a federal schedule. The schedule decides what a refill request may do, which is why the schedule is read before the queue is worked.
Medication reconciliation: Comparing the medication list in the record against what the patient is actually taking, and naming the differences for a clinician rather than settling them.
Fill history: The dates a prescription was actually filled. Read as arithmetic it shows a gap; why the gap happened is a question to ask and pass on, not to answer.
Behavioral carve-out: A behavioral benefit held and run by a company other than the one on the member's card, which is the entity the desk has to reach. Verify with the holder named in the eligibility response, not with the medical plan.
Exclusion: A stated reason that takes a case out of a rule's reach: in quality work, a reason a measure names for not counting a person; in coverage, a service a plan says it does not pay for. Either way the rule names it and the desk only points at it.
Home health eligibility: The set of conditions a patient has to meet for home health, each one evidenced in the record. Each condition is evidenced in the record or the row stays open.
Hospice election: The patient's signed choice of hospice care, which changes what else may be billed and by whom. It changes who bills for what, so it is checked before anything is sent.
Local coverage determination: A coverage rule a regional contractor publishes, which says what the record has to show for a service in that area. Read the contractor's own page rather than a summary of it.
Medicaid managed care: State coverage delivered through a contracted plan, so the plan's rules sit on top of the state's. The plan may be no more restrictive than the state programme it delivers.
National coverage determination: A coverage rule set centrally that applies to the whole programme rather than to one region. It applies programme-wide, so a regional rule cannot narrow it away.
Partial hospitalization: A structured programme of several hours a day without an overnight stay, which a plan reads as its own level of care rather than as a run of visits. Book it against the programme's own rules, not the clinic's slot grid.
Qualified health plan: A plan certified to be sold on a health insurance marketplace, carrying that marketplace's rules with it. Marketplace rules travel with it, so the appeal route differs.

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