Claims

The date on which a payer's claims processing system completed adjudication, determining payment, denial, or adjustment of a submitted claim. Critical for calculating claim lag, measuring payer turnaround times, and reconciling remittance data in claims and financial reporting systems.

A coded field populated from ANSI X12 835 remittance transactions containing Claim Adjustment Reason Codes (CARC) or Remittance Advice Remark Codes (RARC) that specify the basis for payer payment modifications. Referenced in claims management systems, EHR revenue cycle modules, and PBM adjudication platforms for audit and appeal processing.

Medication reconciliation service type documented in EHR clinical notes, pharmacy management systems, and MTM billing records where a patient presents all current medications for pharmacist review. Billed under CPT medication therapy management codes and tracked in PBM quality program reporting for adherence and polypharmacy risk identification.

The federal agency within HHS responsible for administering Medicare, Medicaid, CHIP, and the Health Insurance Marketplace. CMS sets reimbursement rates, quality reporting requirements, and coding standards including ICD-10, CPT, and HCPCS. Primary regulatory authority for healthcare payer data systems and value-based care programs.

A standardized code segment in ANSI X12 835 transaction sets that categorizes the reason for a payment adjustment. Common values include CO (Contractual Obligation), PR (Patient Responsibility), and OA (Other Adjustment), used by payers and clearinghouses during remittance processing.

An industry-standard CARC code published by WEDI and used in 835 remittance transactions to explain why a claim line was not paid at the submitted charge amount. For example, CARC 45 indicates the charge exceeds the contracted fee schedule, guiding downstream denial management and appeals workflows.

The primary identifier assigned by the claim submitter to uniquely track a healthcare claim record as specified in CLM01 of the X12 837 transaction. Used by providers to reference specific claims in status inquiries, appeals, and adjustments. Also called the submitter claim control number.

A code identifying the type of insurance coverage or health plan responsible for primary payment of a healthcare claim as specified in loop 2000B of the X12 837 transaction. Used in claims adjudication to determine coordination of benefits sequencing and apply correct reimbursement rules.

A claim that has been denied by a payer during the adjudication process due to missing information, eligibility issues, or policy violations. Rejected claims must be corrected and resubmitted. Tracked as a key metric in revenue cycle management and provider billing operations.

Standardized code indicating the final adjudication status of a claim in payer and EHR systems. Values include 1=Processed as Primary, 2=Processed as Secondary, and 4=Denied. Critical for claims reconciliation, denial management workflows, and downstream analytics in clearinghouse and adjudication platforms.

The process by which a health insurance payer evaluates and processes a healthcare claim to determine the amount payable under the member benefit plan. Includes eligibility verification, benefit determination, coordination of benefits, and payment calculation. Core function of healthcare payer operations.

A fixed dollar amount paid by a health plan member at the point of service for a covered healthcare service or prescription. Copayments do not count toward the deductible in most plans but may count toward the out-of-pocket maximum. Common in HMO, PPO, and Medicare Advantage benefit designs.

A standardized coding system maintained by the AMA used to report medical, surgical, and diagnostic procedures and services performed by healthcare providers. CPT codes are required on all professional claims submitted to Medicare, Medicaid, and commercial payers for reimbursement of physician services.

The fixed annual dollar threshold a member must satisfy through out-of-pocket payments before the health plan begins reimbursing covered medical, pharmacy, or behavioral health claims. Tracked in EHR, claims adjudication, PBM, and member enrollment systems.

The HIPAA standard electronic transaction for submitting dental healthcare claims from dentists and oral surgeons to insurance payers. Uses the X12 837D format and replaces the paper ADA dental claim form. Includes dental procedure codes, tooth numbers, and oral cavity designations.

HIPAA-standard 835 transaction file transmitted by payers to providers detailing claims payment decisions, adjudicated amounts, adjustment reason codes (CARCs), and remark codes (RARCs). Used in revenue cycle management systems to automate payment posting and reconciliation against submitted 837 claim transactions.

Integration middleware architecture enabling standardized communication, message routing, data transformation, and orchestration between disparate healthcare systems such as EHRs, claims platforms, and PBMs. Supports HL7, FHIR, and EDI 837/835 transaction flows in enterprise health IT integration environments.

A unique identifier assigned by CMS to Medicare beneficiaries based on their Social Security Number. Used on Medicare claims prior to transition to the Medicare Beneficiary Identifier. Being phased out to protect beneficiary Social Security numbers from identity theft in Medicare data systems.

An employer-funded benefit account allowing employees to be reimbursed for qualified medical expenses and individual health insurance premiums tax-free. HRAs are owned by the employer and do not roll over unless the employer allows it. Used in benefits administration and member enrollment data systems.