Healthcare RCM & Medical Billing Glossary
Plain-English definitions for 405 revenue cycle, medical-billing, coding, denial, payer, and compliance terms. Every entry leads with a 40–60 word answer block, followed by a formula (where one exists), an industry benchmark, and a worked example — reviewer-authored, cited inline.
Reviewed by QuickIntell Editorial Team · Last reviewed
UpdatedFilter by category
Showing 40 terms in Payer. Clear filters.
A
- ACA MarketplacePayeraka Health Insurance Marketplace, Exchange, Healthcare.gov
The ACA Marketplace is the federal or state-operated health insurance exchange created by the Affordable Care Act where individuals and sma…
- Accountable Care OrganizationPayeraka ACO, Medicare ACO, MSSP ACO
An Accountable Care Organization (ACO) is a network of providers that accepts shared accountability for quality and total cost of care for…
- Ambulatory Surgery Center (ASC)Payeraka ASC, Outpatient Surgery Center, Surgicenter
An Ambulatory Surgery Center (ASC) is a Medicare-certified outpatient facility providing same-day surgical services — elective procedures t…
C
- Children's Health Insurance Program (CHIP)Payeraka CHIP, Children's Health Insurance Program, State Children's Health Insurance Program
The Children's Health Insurance Program (CHIP) is a federal-state program providing health coverage to children in families with income too…
- COBRA InsurancePayeraka COBRA, Consolidated Omnibus Budget Reconciliation Act, COBRA Continuation Coverage
COBRA is federal law that lets employees and dependents continue employer-sponsored group health coverage temporarily — typically up to 18…
- CoinsurancePayeraka Cost-Sharing Coinsurance
Coinsurance is the percentage of a covered medical expense that the patient pays after meeting their deductible, with the payer covering th…
- Coordination of BenefitsPayeraka COB, Benefits Coordination
Coordination of Benefits (COB) is the process of determining the order in which multiple insurance plans pay for a covered service when a p…
- CopayPayeraka Copayment, Co-pay
A copay is a fixed dollar amount the patient pays per covered service, typically collected at the time of service. Common copay structures…
E
- Eligibility VerificationPayeraka Benefits Verification, Eligibility and Benefits, E&B Check
Eligibility Verification is the process of confirming a patient's active insurance coverage, plan benefits, copays, deductibles, and coordi…
- Exclusive Provider Organization (EPO)Payeraka EPO, Exclusive Provider Organization
An Exclusive Provider Organization (EPO) is a health plan type that restricts members to in-network providers like an HMO but does not requ…
F
- Flexible Spending Account (FSA)Payeraka FSA, Healthcare FSA, Health Care Flexible Spending Account
A Flexible Spending Account (FSA) is an employer-sponsored pre-tax account used to pay qualified medical expenses. Unlike HSAs, FSAs have l…
- FormularyPayeraka Drug Formulary, Prescription Drug List, PDL
A formulary is a health plan's list of covered prescription drugs, organized by tiers with different copay amounts, and often with utilizat…
H
- Health Maintenance Organization (HMO)Payeraka HMO, Health Maintenance Organization
A Health Maintenance Organization (HMO) is a health plan type that requires members to use in-network providers, select a primary care phys…
- Health Savings Account (HSA)Payeraka HSA, Health Savings Account
A Health Savings Account (HSA) is a tax-advantaged savings account owned by individuals enrolled in an HSA-qualified High-Deductible Health…
- High Deductible Health PlanPayeraka HDHP, High Deductible Plan, HSA Plan
A High Deductible Health Plan (HDHP) is a health plan with a deductible above IRS-defined minimum thresholds ($1,600 individual / $3,200 fa…
M
- Medicaid Managed CarePayeraka MMC, Medicaid MCO, Managed Medicaid
Medicaid Managed Care is the delivery model in which state Medicaid agencies contract with private managed care organizations (MCOs) to coo…
- Medicare AdvantagePayeraka MA, Medicare Part C, MA Plans
Medicare Advantage (MA, also called Medicare Part C) is the private-plan alternative to traditional fee-for-service Medicare. MA plans — of…
- Medicare Part APayeraka Medicare Part A, Hospital Insurance, Medicare Hospital Coverage
Medicare Part A is the hospital-insurance component of Original Medicare, covering inpatient hospital stays, skilled nursing facility stays…
- Medicare Part BPayeraka Medicare Part B, Medical Insurance, Medicare Outpatient Coverage
Medicare Part B is the medical-insurance component of Original Medicare, covering physician services, outpatient hospital services, durable…
- Medicare Part DPayeraka Medicare Part D, Medicare Prescription Drug Coverage, Part D
Medicare Part D is the outpatient prescription-drug-coverage component of Medicare, delivered through private plans contracting with CMS. P…
- Medicare Secondary PayerPayeraka MSP, Medicare Secondary Payer Rules
Medicare Secondary Payer (MSP) rules determine when Medicare pays second to another insurer — typically employer group health plans, worker…
- Medigap (Medicare Supplement Insurance)Payeraka Medigap, Medicare Supplement, Medicare Supplemental Insurance
Medigap is private insurance that supplements Original Medicare (Parts A and B) by covering some or all of the cost-sharing Medicare does n…
P
- Pharmacy Benefit Manager (PBM)Payeraka PBM, Pharmacy Benefit Manager, Pharmacy Benefits Management
A Pharmacy Benefit Manager (PBM) is a third party that administers prescription drug benefits for health plans, employers, and government p…
- Point of Service (POS) PlanPayeraka POS Plan, HMO-POS, Point of Service
A Point of Service (POS) plan is a hybrid health plan type that combines HMO-style PCP gatekeeping with PPO-style out-of-network coverage o…
- PredeterminationPayeraka Predet, Pre-Estimate, Coverage Predetermination
A predetermination is a voluntary pre-service request to a payer for a written determination of whether a planned service will be covered a…
- Preferred Provider Organization (PPO)Payeraka PPO, Preferred Provider Organization
A Preferred Provider Organization (PPO) is a health plan type that contracts with a network of preferred providers offering in-network rate…
- Prior AuthorizationPayeraka PA, Pre-Authorization, Precertification
Prior Authorization is a health plan's requirement that a provider obtain approval before delivering specific services, medications, or dev…
S
- Secondary InsurancePayeraka Secondary Payer, Secondary Coverage
Secondary insurance is the insurance plan that pays after the primary plan has adjudicated a claim, covering some or all of the remaining p…
- Self PayPayeraka Self-Pay, Uninsured, Cash Pay
Self pay is the patient financial class for encounters where the patient — not an insurance plan — is financially responsible for the full…
- Single Case Agreement (SCA)Payeraka SCA, Letter of Agreement, Out-of-Network SCA
A Single Case Agreement is a contract negotiated between an out-of-network provider and a payer for a specific patient's care, establishing…
- Step TherapyPayeraka Step Therapy Protocol, Step Edit, Fail-First Policy
Step therapy is a utilization management policy requiring patients to try and fail on preferred lower-cost medications before the health pl…
- SubrogationPayeraka Subrogation Recovery, Third-Party Recovery, TPR
Subrogation is the legal right of a health plan or insurer to seek reimbursement from a third party responsible for an injury that the plan…
T
- Third-Party Liability (TPL)Payeraka TPL, Third Party Liability, Third-Party Recovery
Third-Party Liability (TPL) is the legal and financial obligation of a non-health-insurance third party — typically an auto, homeowners, wo…
- TRICARE BillingPayeraka TRICARE, Military Healthcare Billing, DoD Health Program
TRICARE billing is the claims workflow for services provided to active-duty military, military retirees, and their dependents under TRICARE…
Turn definitions into operating performance
QuickIntell's platform measures the metrics in this glossary in real time — Days in AR, Clean Claim Rate, First-Pass Resolution Rate, Denial Rate — and runs the workflows that move them.