Eligibility Front End
Eligibility verification is the process of confirming that a patient has active insurance coverage on the date of servic...
Registration Front End
Patient registration is the process of collecting accurate demographic and insurance information when a patient presents...
Insurance Verification Front End
Insurance verification goes beyond eligibility — it confirms the specific benefits and coverage details of the patient's...
Prior Authorization Front End
Prior authorization (pre-authorization or pre-certification) is the process of obtaining approval from the insurance pay...
Medical Necessity Front End
Medical necessity means the service is reasonable and necessary for the diagnosis or treatment of the patient's conditio...
Documentation Clinical & Documentation
Clinical documentation is the written record of the patient encounter, including the history, examination, assessment, a...
Coding Clinical & Documentation
Medical coding is the process of translating clinical documentation into standardized codes — CPT codes for procedures/s...
Modifiers Clinical & Documentation
Modifiers are two-character codes appended to CPT/HCPCS codes to provide additional information about the service. Modif...
Telehealth Clinical & Documentation
Telehealth is the delivery of healthcare services via telecommunications technology. Telehealth services include video v...
Place of Service (POS) Clinical & Documentation
Place of Service (POS) codes identify where the service was rendered. Examples include POS 11 (office), POS 21 (inpatien...
Bundling (NCCI) Clinical & Documentation
Bundling is the process of combining multiple procedures into a single payment. The CMS National Correct Coding Initiati...
National Drug Code (NDC) Clinical & Documentation
The National Drug Code (NDC) is a unique identifier for drug products. CMS requires NDCs to be reported on claims for ph...
Coordination of Benefits Front End
Coordination of Benefits (COB) is the process of determining which insurance payer is primary and which is secondary whe...
Patient Responsibility Front End
Patient responsibility is the portion of the healthcare bill that the patient must pay, including deductibles, copays, c...
Claims Submission Claims & Appeals
Claims submission is the process of sending healthcare claims to the insurance payer for payment. Claims are submitted e...
Timely Filing Claims & Appeals
Timely filing is the deadline for submitting a claim to the payer. Each payer sets its own timely filing deadline — typi...
Appeals Claims & Appeals
An appeal is a formal challenge to a payer's denial of a claim. Appeals are filed when the provider believes the denial ...
Denial Management Claims & Appeals
Denial management is the systematic process of identifying, analyzing, and resolving claim denials. It includes tracking...
Hospital Billing Care Settings
Hospital billing is the process of billing for services rendered in a hospital setting — both inpatient and outpatient. ...
Professional Billing Care Settings
Professional billing is the process of billing for services rendered by a physician or other healthcare professional. Pr...
Inpatient Care Settings
Inpatient billing is for services rendered to a patient who is formally admitted to a hospital. Inpatient claims are bil...
Outpatient Care Settings
Outpatient billing is for services rendered to a patient who is not formally admitted to a hospital. Outpatient services...
Emergency Department Care Settings
Emergency Department (ED) billing is for services rendered in the hospital emergency room. ED services are billed using ...
Observation Care Settings
Observation status is for patients who require monitoring but do not meet inpatient admission criteria. Observation serv...
Surgery Care Settings
Surgical billing is for services rendered during surgical procedures. Surgical CPT codes (10004–69990) include the pre-o...
Therapy (PT/OT/ST) Specialty Services
Therapy billing includes physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP/ST). Thera...
Behavioral Health Specialty Services
Behavioral health billing includes mental health and substance use disorder services. Behavioral health services are bil...
Home Health Specialty Services
Home health billing is for skilled services (nursing, therapy, aide) provided in the patient's home. Medicare home healt...
Hospice Specialty Services
Hospice billing is for palliative care services provided to terminally ill patients with a life expectancy of 6 months o...
Durable Medical Equipment (DME) Specialty Services
Durable Medical Equipment (DME) billing is for reusable medical equipment prescribed for home use — wheelchairs, walkers...
