Adjustments: Insurance adjustments occur after a finalized claim has been reprocessed or corrected, usually resulting in a clawback. Payers routinely perform audits of finalized claims, and if the reimbursement amount or client responsibility is changed, an adjustment is issued. For more information, see How to View Claim Payments.

Allowed amount: This refers to the maximum amount a plan will pay for a covered healthcare service. If the deductible amount remaining is greater than the allowed amount, the client will owe the allowed amount in full. If the client has a copay or coinsurance, they’ll owe a dollar amount or percentage amount based on their level of coverage, and the insurance will pay the remainder of the allowed amount. This amount may also be referred to as the eligible expense, payment allowance, or negotiated rate.

Benefit level exceptions/single-case agreement: This refers to when an out-of-network provider receives in-network benefits for certain clients because they’ve negotiated an agreement specifically between those clients and the payer.

Billing NPI: Your billing NPI is used to let insurance companies know what entity is billing for the services rendered. The billing NPI can be an individual (Type 1) or an organization/group (Type 2) NPI, and goes in box 33a of the claim form. For more information, see Osmind Claims: System Settings.

CAQH EnrollHub: This is a website that providers may need to enroll through to receive their insurance payments via EFT (Electronic Funds Transfer). This depends on the payer and if they’re using CAQH as their EDI (Electronic Data Interchange).

Carve out: This is when an insurance payer excludes a service from their coverage because another insurance payer is covering that service under the patient's plan.

Clawbacks/take-backs: It’s common for insurance payers to audit claims that they've processed to check for errors. Sometimes they'll find that they've paid too much or too little and will issue new EOBs/ERAs to correct the mistake. How clawbacks/take-backs are processed varies from payer to payer.

Clearinghouse: A clearinghouse serves as a connection to insurance payers. Clearinghouses review and correct claims before submitting them to payers for final processing, and return Payment Reports (ERAs) from the payer.

COB: This stands for Coordination of Benefits. If a client’s insurance is covered by more than one payer, a Coordination of Benefits will be issued outlining which portion of the services each payer covers. This includes which plan is the client’s primary, and which is secondary.

Courtesy billing: This refers to an out-of-network clinician who’s submitting claims to insurance so that the client gets reimbursed directly. The client pays the clinician their full Self-pay fee up-front and waits for reimbursement from the payer.

CMS1500 (formerly HCFA): This is the standard claim form that's used to file insurance claims. This is the only insurance form supported in Osmind.

Coinsurance: A client with coinsurance is responsible for a set percentage of their service costs. Coinsurance normally begins after a client meets their deductible.

Contracted amount/contractual agreement: When a provider becomes credentialed/paneled as an in-network provider, they agree to a contract with the payer. This contract details the amount the payer will pay for the provided services.

Contractual obligation: Also known as a write-off, the contractual obligation is the amount that remains after the client responsibility and contracted amount have been determined. This amount isn’t collected by the provider, or by the insurance payer.

Copay: A copay is a set price that indicates what the provider charges a client up-front. Not all plans have copays, and if they do, they’re generally listed on the client’s insurance ID card. You may also call a payer directly to confirm if a client owes a copay. For more information, see Patient Payments and Copays.

Credentialing or paneling process: This is the process a clinician goes through directly with the payer in order to become an in-network provider. Osmind can't assist with this process.

Deductible: A deductible is a set amount that a client is responsible for meeting before their insurance payer begins covering services.

EDI: This stands for Electronic Data Interchange. This is a form of electronic communication used by companies to exchange data. Clearinghouses and insurance payers, for example, communicate via EDI.

EFT: This stands for Electronic Funds Transfer. This is a direct deposit or wire transfer between two bank accounts. Also known as ACH, many payers offer the option of signing up to receive payments via EFT instead of paper checks. To set up EFT, contact the payer directly.

EIN: This stands for Employer Identification Number and is a Tax ID/TIN. This is a federal tax ID number for non-person entities, such as an LLC or a corporation.

Enrollment: Submitting enrollments in ConnectCenter lets insurance payers know that you’ll be filing claims and/or receiving Payment Reports (ERAs) via Osmind/Change Healthcare. For more information, see Payer Enrollments in ConnectCenter.

EOB: An Explanation of Benefits is a document sent by insurance payers, along with any payment, that summarizes the services being covered. EOBs are received if you are not enrolled with a payer to receive ERAs.

ERA: An Electronic Remittance Advice is the electronic version of an EOB.

HCFA form: This stands for Health Care Financing Administration, and is the former name used to describe a claim form.

ICN: When claims are entered into the Medicare system, they’re issued a 13-digit tracking number known as an Internal Control Number.

Incident-to billing: This refers to claims that are submitted when a supervisee or intern is the rendering provider. States have different requirements for whose name and NPI is entered on the claim, so we recommend reaching out to an insurance payer before submitting claims.

Individual NPI: This is the rendering (Type 1) NPI assigned to an individual clinician.

Loops and segments: These refer to specific boxes on a CMS1500 claim form. This language is used primarily by clearinghouses and payers.

Medicare ID: This is an ID number provided by Medicare to be used when submitting a Medicare enrollment. This is also referred to as a PTAN (Provider Transaction Access Number).

Medicare crossover: Medicare is a unique payer in that they’ll submit a secondary claim on your behalf if the client has their Coordination of Benefits set up. This is referred to as a crossover claim and will take place after Medicare has processed the primary claim. We recommend contacting Medicare to confirm whether or not they’ll submit a crossover claim on your behalf.

NPI: This stands for National Provider Identifier. An NPI is a unique identification number for covered health care providers. NPIs are always 10 digits and are assigned by the Centers for Medicare and Medicaid Services (CMS).

Out-of-pocket max: This refers to the maximum amount of money that a client will have to pay out of their own pocket. Once they’ve accumulated this total amount in charges for services, the insurance payer is expected to cover remaining billable services.

Payer control number: This is a unique reference number that a payer assigns to a claim once it’s entered into their system. Osmind assigns a Patient Control Number (PCN) that becomes the claim ID in Change Healthcare and can be referenced with the payer.

Payer ID: This is a unique number used to identify payers for electronic claim submission. Osmind displays the external payer ID number that is usually visible on the patient's insurance card. You can also use the payer search tool in ConnectCenter to confirm payer IDs.

Payer portal: Most insurance companies have a payer portal where providers and/or clients can log in. In the payer portal for some payers, a provider can check the status of claims and review remittance advice.

PTAN: A Provider Transaction Access Number is a unique number Medicare assigns to clinicians in their network. You can contact Medicare directly to confirm your PTAN.

Rendering NPI: This is the NPI that goes in box 24j of the claim form and lets insurance payers know who was the individual who provided/rendered the services on that claim form. This will typically be a Type 1 NPI.

Submitter: This refers to the clearinghouse the claim is being submitted through. Osmind partners with Change Healthcare as the clearinghouse. When you are activated for claims, Osmind will share your practice's Change Healthcare Submitter ID.

Subscriber: The subscriber is the primary insured person on the plan. This can be the client, their spouse, a parent, or another party.

Superbills: A superbill is also known as a Statement for Insurance Reimbursement. This is a statement out-of-network clinicians give to their clients so they can request reimbursement from insurance themselves after paying for services up-front in full. The information in this statement is the same information that’s included in an insurance claim.

Tax ID: A federal Tax ID is your taxpayer identification number and is also known as a TIN or EIN.

Taxonomy code: A taxonomy code is a number that specifies a provider’s specialty. This information is required for claims to be processed and populates in box 33b of our claim form.

Third-party clearinghouse: Also known as a trading partner, a third party clearinghouse is another entity our clearinghouse works with to be able to establish a claim filing and/or ERA connection with a payer.

TIN: This stands for Tax Identification Number, and is also known as a Tax ID or EIN.

Trading partner ID or submitter ID: This is the unique identifier that a payer gives each clearinghouse.

Write-off: For insurance clients, a write-off, or contractual obligation, is the portion of a service’s fee that’s covered by neither the payer or the client’s responsibility. For self-pay clients, this is a portion of a service’s fee that you can choose not to charge a client.

835: This is a term used by clearinghouses and payers to refer to an electronic Payment Report enrollment.

837p: This is a term used by clearinghouses and payers to refer to an electronic claim filing enrollment.