Resource Center
Credentialing Glossary
Definitions for every credentialing, enrollment, and compliance term you need to know, from A to Z.
ABMS
The American Board of Medical Specialties — the umbrella organization overseeing 24 medical specialty boards that certify physicians in the United Sta...
Accreditation
Formal recognition by an authorized body, such as NCQA or URAC, that a healthcare organization meets established quality standards and best practices...
Add-On Code
A CPT code that can only be billed in conjunction with a primary procedure code, not on its own. Identified by a + symbol in the CPT book. Common exam...
Adjudication
The payer process of evaluating a claim and determining payment. Steps: receipt and acknowledgment, edits and validation, medical review (if flagged),...
Adverse Action
A negative action taken against a healthcare provider by a licensing board, hospital, payer, or professional society that affects their ability to pra...
Adverse Determination
A payer's decision to deny, reduce, or terminate coverage for a requested healthcare service based on medical necessity, benefit coverage, or other cr...
AHP
Allied Health Professional — a healthcare provider who is not a physician but delivers clinical services, including nurse practitioners, physician ass...
Allowed Amount
The maximum amount a health plan will pay for a covered service, as determined by the provider's contract or the plan's fee schedule.
Anti-Kickback Statute
A federal criminal law that prohibits offering, paying, soliciting, or receiving anything of value to induce or reward referrals of items or services...
APC (Ambulatory Payment Classification)
Outpatient hospital payment classification under the OPPS (Outpatient Prospective Payment System). 931 active APCs in 2026. Each HCPCS code maps to a...
Appeal
A formal request by a provider or patient to an insurance payer to reconsider a denied claim or coverage decision, providing additional documentation...
Appeal vs Reconsideration
A reconsideration is a request for the payer to re-review the original claim with no new information (often automated, takes 7 to 30 days). An appeal...
Assignment of Benefits
An authorization by a patient that directs their insurance payer to send payment directly to the healthcare provider rather than to the patient.
Attestation
A formal written statement by a provider affirming the accuracy and completeness of their credentialing application, including declarations regarding...
Audit
A systematic review and examination of a provider's or organization's records, processes, and compliance with credentialing standards, regulatory requ...
Availity
A multi-payer health information network and portal used by providers to verify eligibility, submit claims, check claim status, and manage prior autho...
BAA
A Business Associate Agreement is a required HIPAA contract between a covered entity and a business associate that establishes permitted uses and disc...
Balance Billing
The practice of billing a patient for the difference between the provider's billed charge and the amount the insurance plan paid or allowed.
Behavioral Health Credentialing
The credentialing process specific to behavioral health providers including psychiatrists, psychologists, social workers, counselors, and substance ab...
Bill Type / TOB
Three-digit Type of Bill code on the UB-04 indicating facility type and bill purpose. First digit = facility type (1 hospital, 2 SNF, 3 home health),...
Billing Provider
The entity that submits a claim to a payer for reimbursement. In a group practice, the billing provider is typically the group entity, while individua...
Board Certification
A voluntary credential earned by a physician who has completed residency training and passed a rigorous specialty exam administered by an ABMS member...
Bundling and Unbundling
Bundling means combining multiple component services into a single comprehensive code (correct coding). Unbundling is fragmenting a comprehensive serv...
Capitation
A payment model where a payer pays a provider a fixed amount per member per month regardless of whether the member receives any services during that p...
CAQH
The Council for Affordable Quality Health Care, an organization that maintains a universal provider database (CAQH ProView) used by most health plans...
CARC
Claim Adjustment Reason Code. X12 standardized 308 codes (1 to 308) explaining why a claim line was adjusted. Always paired with a Group Code (CO, PR,...
CC and MCC
Complication or Comorbidity (CC) and Major Complication or Comorbidity (MCC) designations on inpatient diagnoses that drive MS-DRG assignment. 18,389...
Claim Denial Rate
The percentage of submitted claims that a payer denies, measured as a key performance indicator for billing operations and revenue cycle management.
Claim Scrubbing
The automated process of reviewing healthcare claims for errors, inconsistencies, and compliance issues before they are submitted to payers.
Claims Adjudication
The process by which a payer receives, reviews, and determines payment for a healthcare claim, including verification of eligibility, coverage, coding...
Claims Processing
The end-to-end system by which payers receive, review, adjudicate, and pay healthcare claims submitted by providers.
Clean Claim
A healthcare insurance claim that is submitted with all required information, correct coding, and proper documentation, allowing the payer to process...
Clearinghouse
An intermediary company that receives claims from providers, reformats them to meet each payer's specifications, scrubs them for errors, and transmits...
CLIA
The Clinical Laboratory Improvement Amendments regulate all laboratory testing performed on humans in the United States, requiring certification for a...
CLIA Waiver
A type of CLIA certificate that allows a practice to perform simple, low-risk laboratory tests that have been approved by the FDA for waived testing.
Closed Panel
A payer network that is not accepting new provider applications in a particular specialty or geographic area because the existing network is considere...
CMS-1500
Standard paper claim form for professional (non-facility) billing. Maintained by NUCC. 33 fields including patient demographics (1-13), provider infor...
CMS-855
The family of Medicare enrollment application forms used to enroll providers, suppliers, and organizations in the Medicare program through PECOS.
Coinsurance
The percentage of costs for a covered healthcare service that a patient pays after meeting their deductible, with the insurance plan paying the remain...
Collaborative Practice Agreement
A formal written agreement between a physician and a nurse practitioner or physician assistant defining the terms of their professional collaboration,...
Compliance Officer
A designated individual within a healthcare organization responsible for developing, implementing, and monitoring the organization's compliance progra...
Compliance Program
A structured system of policies, procedures, training, and monitoring designed to prevent, detect, and correct violations of healthcare laws and regul...
Continuing Medical Education
Ongoing educational activities that healthcare providers complete to maintain their professional knowledge, licensure, and board certification through...
Contract Negotiation
The process of negotiating the terms of a provider participation agreement with a payer, including fee schedule rates, payment terms, and contract pro...
Contractual Adjustment
The mandatory write-off equal to the difference between billed charges and the contracted allowed amount. Reported on the 835 with group code CO. Prov...
Conversion Factor
The dollar amount per RVU under the Medicare Physician Fee Schedule. Updated annually by CMS through the final rule, typically published in November a...
Coordination of Benefits
The process of determining which insurance plan pays first when a patient has coverage under two or more health insurance plans.
Copay
A fixed dollar amount that a patient pays at the time of receiving a covered healthcare service, with the insurance plan covering the remaining cost....
Council for Affordable Quality Healthcare
The nonprofit alliance of health plans and trade associations that operates CAQH ProView, the universal credentialing database used by most commercial...
Covered Services
Healthcare services and procedures that are included in an insurance plan's benefits, meaning the payer will reimburse all or part of the cost when re...
CPT (Current Procedural Terminology)
Five-digit code set maintained by the American Medical Association that describes medical, surgical, and diagnostic services. CPT 2026 contains 11,025...
CPT Code
Current Procedural Terminology codes are the standardized numeric codes used to describe medical procedures and services for billing purposes.
Credentialing
The process of verifying a healthcare provider's qualifications, training, licensure, and professional background to ensure they meet the standards re...
Credentialing Application
The formal application submitted by a healthcare provider to a payer or facility requesting enrollment in their provider network, containing all requi...
Credentialing Audit
A review conducted by a regulatory body, accrediting organization, or payer to evaluate whether a healthcare organization's credentialing process meet...
Credentialing Backlog
The accumulation of unprocessed credentialing applications at a payer or facility, resulting in extended processing times beyond normal timelines.
Credentialing Best Practices
Proven strategies and approaches that minimize enrollment delays, reduce errors, and optimize the credentialing process for healthcare providers and o...
Credentialing Committee
A committee of healthcare professionals that reviews provider credentialing applications and makes formal decisions to approve, deny, or defer enrollm...
Credentialing Compliance
Adherence to all regulatory, accreditation, and contractual requirements governing the credentialing process, including timely verifications, proper d...
Credentialing Database
A centralized electronic system that stores and manages provider credentialing information, verification results, and enrollment status across multipl...
Credentialing Denial
A formal decision by a payer or facility to reject a provider's credentialing application, preventing them from participating in the network.
Credentialing File
The complete collection of documents, verifications, and records maintained for a provider throughout the credentialing and re-credentialing process.
Credentialing Gap Analysis
A systematic review comparing a provider's current credentials and enrollment status against the requirements of target payers and facilities.
Credentialing Packet
The complete set of documents a provider assembles for a credentialing application, including licenses, certificates, insurance proof, work history, a...
Credentialing Process Improvement
Systematic efforts to reduce credentialing cycle times, decrease application errors, and improve the efficiency of the provider enrollment process.
Credentialing Software
Technology platforms designed to automate and manage the credentialing process, including application tracking, document management, verification work...
Credentialing Specialist
A healthcare administrative professional who manages the credentialing and enrollment process for providers, handling applications, document collectio...
Credentialing Standards
The established criteria and requirements set by accrediting bodies like NCQA, regulatory agencies, and payers that define how the credentialing proce...
Credentialing Timeline
The expected duration from application submission to enrollment approval with a payer, typically ranging from 30 to 150 days depending on the payer an...
Credentialing Timeout
The situation where a credentialing verification expires because the overall process took too long, requiring the verification to be repeated from scr...
Credentialing Turnaround Time
The total number of days from application submission to enrollment approval, used as a key performance metric for credentialing operations.
Credentialing Verification Letter
An official letter from a credentialing body, payer, or licensing board confirming a provider's current credentialing status, enrollment, or licensure...
Credentialing Verification Organization
A third-party entity that performs primary source verification of healthcare provider credentials on behalf of health plans, hospitals, and other orga...
Credentialing Workflow
The structured sequence of steps in the credentialing process, from initial application through verification, committee review, contracting, and provi...
CVO
A Credentials Verification Organization is a third-party entity that performs primary source verification of provider credentials on behalf of health...
DEA
The Drug Enforcement Administration registration is a federal license that authorizes healthcare providers to prescribe and dispense controlled substa...
Deductible
The amount a patient must pay out of pocket for covered healthcare services before the insurance plan begins to reimburse. Deductibles reset annually...
Delegated Credentialing
An arrangement where a health plan delegates the credentialing process to a qualified healthcare organization, such as a hospital or CVO, that meets t...
Denied Claim
A healthcare claim that has been reviewed and rejected by an insurance payer due to errors, missing information, lack of coverage, or failure to meet...
Downstream Provider
A healthcare provider who receives referrals or subcontracts from another provider or organization that holds the primary contract with a payer.
E/M (Evaluation and Management)
CPT code family covering office visits, hospital visits, consultations, and other cognitive (non-procedural) physician work. Office E/M codes (99202-9...
ECFMG Certification
A certification from the Educational Commission for Foreign Medical Graduates required for international medical graduates who wish to enter graduate...
EDI 270/271
Eligibility verification transaction. 270 is the request you send to a payer (subscriber, date of service, service type code), 271 is the response sho...
EDI 276/277
Claim status transaction. 276 is the request asking the payer about claim status, 277 is the response (received, in process, paid, denied, additional...
EDI 835 / ERA
Electronic Remittance Advice. The X12 transaction payers send back showing claim adjudication results: charges, allowed amount, paid amount, patient r...
EDI 837
X12 healthcare claim transaction. 837P is professional, 837I is institutional, 837D is dental. Required HIPAA standard for electronic claim submission...
Effective Date
The date on which a provider's enrollment or network participation becomes active, allowing them to begin billing a payer for services.
Electronic Data Interchange
The electronic exchange of healthcare information between providers, payers, and clearinghouses using standardized formats defined by HIPAA transactio...
Electronic Funds Transfer
The direct deposit of insurance payments into a provider's bank account, replacing paper checks with faster electronic payment processing.
Empanelment
The process of assigning members to a specific primary care provider within a managed care plan, creating the provider's patient panel.
Enrollment Effective Date Gap
The period between when a provider begins seeing patients and when their payer enrollment becomes effective, during which services cannot be billed to...
Enrollment Specialist
A healthcare administrative professional who specifically handles provider enrollment with insurance payers, managing applications from submission thr...
EOB
Explanation of Benefits. The patient-facing document a payer mails or posts to the member portal showing what was billed, allowed, paid, and what the...
EPO
An Exclusive Provider Organization is a managed care plan similar to a PPO but with no out-of-network coverage except in emergencies, requiring member...
ERA/EFT
Electronic Remittance Advice and Electronic Funds Transfer — the electronic payment notification and direct deposit system used by payers to pay provi...
Expedited Credentialing
An accelerated credentialing process offered by some payers for providers in high-demand specialties, underserved areas, or urgent staffing situations...
Explanation of Benefits
A statement from an insurance payer sent to the member after a claim is processed, detailing the services billed, the amount covered, the provider's a...
Fee Schedule
A complete listing of fees and reimbursement rates that an insurance payer will pay for specific medical services and procedures, forming the basis of...
Fee-for-Service vs Value-Based
Fee-for-Service (FFS) pays per encounter or service rendered (volume-based). Value-Based Care pays for outcomes, quality measures, or population healt...
FQHC
A Federally Qualified Health Center is a community-based healthcare provider that receives federal funding to provide primary care services in underse...
Global Period
The bundled time window after a procedure during which related E/M services are not separately billable. Major surgeries (90-day global) bundle pre-op...
Good Faith Estimate
A written estimate of expected charges for scheduled healthcare services that providers must give to uninsured or self-pay patients under the No Surpr...
GPCI
Geographic Practice Cost Index. Three multipliers (work, practice expense, malpractice) Medicare applies to RVUs to adjust payment for cost-of-living...
Grievance
A formal complaint filed by a member or provider regarding dissatisfaction with the quality of care, access to services, or the administrative process...
Group Practice
A medical practice in which multiple healthcare providers share administrative resources, facilities, and often a group NPI number, and may be credent...
HCC (Hierarchical Condition Category)
CMS risk-adjustment categories used to predict cost for Medicare Advantage and ACA marketplace populations. CMS-HCC v28 (current 2026 version) include...
HCPCS
The Healthcare Common Procedure Coding System is a coding system used to identify healthcare services, supplies, and equipment for billing purposes, s...
HCPCS Level II
Healthcare Common Procedure Coding System Level II covers products, supplies, and services not in CPT, including durable medical equipment (DME), drug...
HIPAA
The Health Insurance Portability and Accountability Act is a federal law that establishes national standards for protecting sensitive patient health i...
HMO
A Health Maintenance Organization is a managed care plan that typically requires members to choose a primary care physician and obtain referrals for s...
ICD-10
The International Classification of Diseases, 10th Revision, is the coding system used to describe diagnoses and the reasons for healthcare services.
ICD-10-CM
International Classification of Diseases, 10th Revision, Clinical Modification. Diagnosis code set used on US healthcare claims since October 1, 2015....
ICD-10-PCS
Procedure Coding System used on inpatient hospital claims (UB-04). 79,115 codes in 2026. Each PCS code is exactly 7 characters built from a structured...
Incident-to Billing
A Medicare billing arrangement where services provided by qualified staff under a physician's direct supervision are billed under the physician's NPI...
Independent Dispute Resolution
The arbitration process established by the No Surprises Act for resolving payment disputes between out-of-network providers and payers when they canno...
Interstate Medical Licensure Compact
An agreement among participating states that creates an expedited pathway for physicians to obtain medical licenses in multiple states without submitt...
LCD (Local Coverage Determination)
Coverage policy issued by a Medicare Administrative Contractor (MAC) for its jurisdiction when no NCD exists. 12,358 active LCDs across 12 MAC jurisdi...
Locum Tenens
A temporary practice arrangement where a healthcare provider fills in for another provider on a short-term basis, often requiring specific credentiali...
Locum Tenens Credentialing
The credentialing process for temporary or substitute healthcare providers who fill in at practices or facilities on a short-term basis.
MAC
A Medicare Administrative Contractor is a private company that CMS contracts with to process Medicare claims and handle provider enrollment for a spec...
MAC (Medicare Administrative Contractor)
Private contractor that processes Medicare Part A and Part B claims for an assigned jurisdiction. 12 active MAC jurisdictions covering all 50 states p...
Malpractice Insurance
Professional liability insurance that protects healthcare providers against claims of medical negligence or errors, covering legal defense costs and p...
Malpractice Tail Coverage
An insurance policy extension that covers claims filed after a claims-made malpractice policy ends, protecting against lawsuits for incidents that occ...
Managed Care
A healthcare delivery system organized to manage cost, utilization, and quality through techniques such as provider networks, referral requirements, a...
MCO (Managed Care Organization)
Health plan that contracts with state Medicaid programs (or commercial sponsors) to administer benefits to enrolled members. Most state Medicaid progr...
MDM (Medical Decision Making)
The cognitive complexity element of E/M code selection (since 2021 office E/M revision). Three components: Number/Complexity of Problems Addressed, Am...
Medical License
A state-issued authorization that permits a physician to practice medicine within that state's jurisdiction, obtained by meeting education, examinatio...
Medical Necessity
The determination that a healthcare service or procedure is clinically appropriate, necessary for the diagnosis or treatment of a condition, and meets...
Medical Staff Office
The hospital department responsible for managing provider credentialing, privileging, medical staff governance, and compliance with accreditation stan...
Medicare Advantage
A type of Medicare plan offered by private insurance companies that contracts with CMS to provide Medicare Part A and Part B benefits, often including...
Medicare Enrollment
The process of registering as a Medicare provider through PECOS using the CMS-855 application forms, enabling a provider to bill Medicare for services...
Medicare Part B
The component of Medicare that covers outpatient medical services including physician visits, diagnostic tests, preventive care, and durable medical e...
Modifier
A two-character code appended to a CPT code to provide additional information about the service performed, such as which side of the body or whether t...
MS-DRG
Medicare Severity Diagnosis Related Group. Inpatient hospital payment classification with 770 active DRGs in v43. Each DRG has a relative weight that...
MUE (Medically Unlikely Edits)
NCCI Medically Unlikely Edits set the maximum units of a HCPCS/CPT code one provider can bill for one beneficiary on one date of service. 33,223 activ...
Multi-State Licensing
The process of obtaining and maintaining medical licenses in multiple states, required for providers who practice across state lines or provide telehe...
National Plan and Provider Enumeration System
The official name for NPPES — the CMS system that assigns and manages NPI numbers for all healthcare providers and health plans in the United States.
National Practitioner Data Bank
The full name for the NPDB — a federal repository of adverse action and malpractice payment reports for healthcare practitioners, used by payers and h...
National Provider Identifier Standard
The HIPAA Administrative Simplification standard that established the NPI as the universal identifier for healthcare providers in all electronic healt...
NCCI Edits (PTP)
National Correct Coding Initiative Procedure-to-Procedure edits prevent billing two CPT codes together that should be bundled. CMS publishes 2.6M prac...
NCD (National Coverage Determination)
CMS national policy specifying when an item or service is covered under Medicare. 357 active NCDs cover items like cardiac defibrillators, bariatric s...
NCQA
The National Committee for Quality Assurance is an independent organization that accredits and certifies health plans and CVOs, and sets the gold stan...
NDC (National Drug Code)
FDA-assigned 10 or 11 digit identifier for human drugs and biologics, formatted as labeler-product-package (e.g., 0078-0658-15). Required on most J-co...
Network Adequacy
The requirement that a health plan's provider network has enough providers in each specialty and geographic area to give members reasonable access to...
Network Contract
The legal agreement between a healthcare provider and a payer that establishes the terms of network participation, including fee schedules, payment te...
Network Leakage
The loss of patients and revenue when health plan members seek care from out-of-network providers instead of staying within the payer's contracted pro...
Network Status
A provider's participation status with a specific insurance payer, indicating whether they are in-network (contracted) or out-of-network (non-contract...
NPDB
The National Practitioner Data Bank is a federal repository of reports on medical malpractice payments, adverse licensure actions, adverse clinical pr...
NPI
The National Provider Identifier is a unique 10-digit identification number issued by CMS to healthcare providers, required for all HIPAA-standard adm...
NPPES
The National Plan and Provider Enumeration System is the CMS system used to assign and manage National Provider Identifier numbers for healthcare prov...
OIG (Office of Inspector General)
HHS oversight body that investigates fraud, waste, and abuse in Medicare and Medicaid. Publishes annual Work Plan listing audit focus areas and Strike...
OIG Exclusion
A determination by the Office of Inspector General that a provider is excluded from participation in all federal healthcare programs, meaning no feder...
Opt-In Provider
A healthcare provider who chooses to participate in an insurance network by signing a participation agreement and accepting the payer's terms includin...
Opt-Out Provider
A healthcare provider who has formally opted out of the Medicare program, choosing to see Medicare beneficiaries only under private contracts rather t...
Out-of-Network
A healthcare provider who does not have a contract with a particular insurance payer, meaning patients may pay higher out-of-pocket costs and the prov...
Out-of-Pocket Maximum
The most a patient will pay for covered healthcare services in a plan year, after which the insurance plan pays 100% of covered services.
Participating Provider
A healthcare provider who has signed a contract with an insurance payer to provide services to the plan's members at negotiated rates, also known as a...
Payer
An insurance company, health plan, or government program (such as Medicare or Medicaid) that reimburses healthcare providers for medical services rend...
Payer Credentialing Requirements
The specific set of qualifications, documents, and verifications that each insurance payer requires before approving a provider for network participat...
Payer Enrollment Checklist
A payer-specific list of requirements, documents, and steps needed to complete enrollment with a particular insurance company.
Payer ID
A unique identifier assigned to each insurance payer, used by clearinghouses and billing systems to route electronic claims to the correct payer for p...
Payer Mix
The proportion of a practice's patients covered by each type of insurance — Medicare, Medicaid, commercial, self-pay — which directly affects the prac...
PECOS
The Provider Enrollment, Chain, and Ownership System is the online portal used by healthcare providers to enroll in Medicare and manage their Medicare...
Peer Review
A process in which a provider's clinical performance, decision-making, and outcomes are evaluated by other qualified providers in the same or similar...
Peer-to-Peer Review
A direct conversation between the rendering provider (or designated proxy) and the payer medical director to discuss a denied claim or denied prior au...
PHI
Protected Health Information is any individually identifiable health information created, received, maintained, or transmitted by a covered entity or...
Place of Service Code
A two-digit code on a claim that indicates where the healthcare service was provided, affecting how the claim is processed and how much the payer reim...
POS
A Point of Service plan is a managed care plan that combines features of HMOs and PPOs, requiring a primary care referral for specialists but allowing...
POS (Place of Service)
Two-digit code on the CMS-1500 indicating where the service was rendered. 51 active codes. Most common: 11 (office), 21 (inpatient hospital), 22 (outp...
PPO
A Preferred Provider Organization is a managed care plan that offers a network of contracted providers at lower costs to members, while still providin...
Practitioner
A healthcare professional who provides clinical services directly to patients, including physicians, nurse practitioners, physician assistants, dentis...
Predetermination
A non-binding payer review of whether a planned service would be covered, used when prior authorization is not required but coverage is uncertain. Dif...
Premium
The periodic payment made by or on behalf of a member to maintain health insurance coverage, typically paid monthly regardless of whether healthcare s...
Prescriptive Authority
The legal authorization granted to a healthcare provider, such as an NP or PA, to prescribe medications. Requirements vary by state and may include co...
Primary Source Verification
The process of verifying a provider's credentials directly from the original issuing source, such as medical schools, licensing boards, and certificat...
Prior Authorization
A requirement by an insurance payer that a provider must obtain approval before delivering certain services, procedures, or medications in order for t...
Privileges
The specific clinical services and procedures a healthcare provider is authorized to perform at a particular healthcare facility, granted based on the...
Privileging
The hospital-specific process of authorizing a credentialed provider to perform specific clinical services and procedures within that facility.
Professional Liability
Insurance coverage that protects healthcare providers against claims of negligence, errors, or omissions in the delivery of professional services.
Provider Credentialing Checklist
A structured list of all documents, verifications, and steps required to complete the credentialing process for a healthcare provider.
Provider Credentialing Services
Third-party companies that handle the credentialing and enrollment process on behalf of healthcare providers, managing applications, follow-ups, and o...
Provider Data Management
The ongoing process of maintaining accurate and current provider information across all payers, directories, licensing boards, and credentialing datab...
Provider Directory
A searchable listing of all healthcare providers in a payer's network, used by members to find in-network providers in their area.
Provider Enrollment
The process by which a healthcare provider applies to participate in an insurance payer's network, allowing the provider to bill and receive reimburse...
Provider Enrollment Application
The formal application form submitted to a specific payer to request enrollment in their provider network, containing provider information, practice d...
Provider Enrollment Specialist
A healthcare administrative professional who manages the specific process of enrolling providers with insurance payers, handling applications, follow-...
Provider Load
The process of entering a newly credentialed provider into a payer's claims processing system so that claims submitted under their NPI can be adjudica...
Provider Manual
A comprehensive reference document published by each payer that outlines billing procedures, coverage policies, prior authorization requirements, and...
Provider Network
The group of healthcare providers, hospitals, and facilities that have contracted with a payer to provide services to the payer's members at negotiate...
Provider Number
A unique identifier assigned by a payer to a credentialed provider, used for claims processing, provider directory listings, and enrollment management...
Provider Onboarding
The comprehensive process of integrating a new provider into a practice or health system, including credentialing, enrollment, IT setup, orientation,...
Provider Relations
The department within a health plan responsible for managing relationships with participating providers, handling enrollment, resolving issues, and co...
Provider Termination
The process by which a provider's participation in a payer's network is ended, either voluntarily by the provider or involuntarily by the payer.
Provider Type
The classification of a healthcare provider based on their professional training and licensure, such as physician, nurse practitioner, physician assis...
Provider Verification
The process of confirming that a healthcare provider's credentials, qualifications, and professional standing are current and valid through direct con...
PTAN
Provider Transaction Access Number — the unique identifier Medicare assigns to each enrolled provider, used for claims processing and enrollment manag...
RADV Audit
Risk Adjustment Data Validation audit. CMS audit of Medicare Advantage plans verifying that submitted HCC diagnoses are supported by medical records....
RAF Score
Risk Adjustment Factor. The numeric multiplier applied to base capitation in Medicare Advantage (and ACA marketplace) reflecting patient health risk....
RARC
Remittance Advice Remark Code. Supplemental code that adds detail to a CARC. 1,198 active codes in 2026. Format: M-prefix (informational, e.g., M1) or...
RBRVS
The Resource-Based Relative Value Scale is the methodology Medicare uses to calculate physician payment rates based on the resources required to provi...
Re-credentialing
The periodic process, typically occurring every three years, in which a provider's credentials are re-verified to ensure they continue to meet the pay...
Reassignment of Benefits
A Medicare enrollment action where an individual provider authorizes their Medicare payments to be made to a group practice or employer instead of dir...
Rendering Provider
The healthcare provider who personally performed or supervised the service being billed. The rendering provider's NPI appears on the claim as the indi...
Retroactive Billing
The practice of billing a payer for services provided before the provider's official enrollment effective date, allowed by some payers under specific...
Revalidation
The periodic process of updating and re-verifying a provider's Medicare enrollment to ensure their information is current and they continue to meet en...
Revenue Code
Four-digit code on the UB-04 hospital claim describing where the service was performed or what type of service it was. 385 active codes. Examples: 025...
Revenue Cycle Management
The complete financial process of healthcare from patient registration through final payment, encompassing scheduling, eligibility verification, codin...
Roster Billing
A billing arrangement where individual providers bill under a group practice's NPI and tax ID, with each provider listed as the rendering provider on...
RVU (Relative Value Unit)
The work value assigned to a CPT or HCPCS code under RBRVS, broken into three components: Work RVU (physician effort), Practice Expense RVU (overhead,...
Sanctions
Disciplinary actions taken against a healthcare provider by a licensing board, government agency, or professional organization, which can include fine...
Scope of Practice
The range of healthcare services and procedures that a licensed provider is legally authorized to perform based on their education, training, licensur...
Service Area
The geographic region where a health plan is licensed to operate and enroll members, which determines which providers need to be included in the plan'...
Single Case Agreement
A one-time contract between an out-of-network provider and a payer to provide specific services to a specific patient at an agreed-upon rate.
Solo Practice
A medical practice owned and operated by a single healthcare provider who is independently responsible for all administrative, clinical, and credentia...
Stark Law
A federal law that prohibits physicians from referring patients for designated health services to entities with which the physician or an immediate fa...
State License
A professional license issued by a state regulatory board that authorizes a healthcare provider to practice their discipline within that state, subjec...
State Licensing Board
The government agency in each state responsible for issuing, renewing, and regulating professional licenses for healthcare providers, and for investig...
Superbill
An itemized form used by healthcare providers to document the services provided during a patient visit, including diagnosis codes and procedure codes,...
Supervision Requirements
Legal and regulatory requirements specifying the level of physician oversight needed for non-physician providers to practice, varying by state and pro...
Surprise Billing
An unexpected medical bill a patient receives when they unknowingly receive care from an out-of-network provider, particularly in emergency situations...
Taxonomy Code
A unique 10-character alphanumeric code assigned to healthcare providers that classifies their specialty, subspecialty, and provider type for use in e...
Telehealth Credentialing
The process of credentialing and enrolling healthcare providers specifically for the delivery of telehealth services, which may involve multi-state li...
Telehealth Parity Law
State or federal legislation requiring insurance payers to cover and reimburse telehealth services at the same rate as equivalent in-person services.
Telemedicine
The delivery of healthcare services remotely using telecommunications technology, which may require separate state licensure and specific payer creden...
Telemedicine Credentialing by Proxy
A CMS provision allowing hospitals to rely on the credentialing decisions of another hospital or telemedicine entity when privileging distant-site tel...
Temporary Privileges
Short-term clinical privileges granted by a hospital or facility to a provider before their full credentialing is complete, allowing them to begin see...
Time-Based Coding
Selecting an E/M code based on total time on the date of encounter rather than MDM. Per 2021 CPT revision: 99202 (15-29 min new), 99203 (30-44), 99204...
Timely Access Standards
Regulatory requirements defining the maximum acceptable wait times for patients to access healthcare services, used to evaluate network adequacy.
Timely Filing
The deadline by which a provider must submit a claim to a payer after the date of service. Claims submitted after the timely filing limit are denied.
UB-04 / CMS-1450
Standard paper claim form for institutional (hospital, SNF, home health) billing. 81 form locators. Includes patient information, occurrence/condition...
UCR
Usual, Customary, and Reasonable — a method payers use to determine the maximum amount they will reimburse for out-of-network services based on charge...
Underpayment
When a payer reimburses less than the contracted allowed amount or fee schedule. Often masked by complete-claim-payment status on the 835 even though...
Upcoding and Downcoding
Upcoding is reporting a higher-paying code than the documentation supports (e.g., billing 99214 when chart only supports 99213). Downcoding is the opp...
UPIN
The Unique Physician Identification Number, a legacy provider identifier that was replaced by the NPI in 2007 and is no longer used for billing or enr...
Utilization Review
The process by which a payer evaluates the medical necessity, appropriateness, and efficiency of healthcare services before, during, or after they are...
Value-Based Care
A healthcare delivery model where providers are reimbursed based on patient health outcomes and quality metrics rather than solely on the volume of se...
Verification of Employment
The process of confirming a provider's work history by contacting current and previous employers, a required step in the credentialing verification pr...