Value-added network (VAN)
A clearinghouse that involves value-added vendors, such as banks, in the processing of claims.
Electronic Healthcare Network Accreditation Commission (EHNAC)
The accreditation agency to check with to see if a clearinghouse is accredited.
Electronic flat file format
A series of fixed-length records (e.g., 25 spaces for patient's name) submitted to payers as a bill for health care services.
Includes all private-sector health plans (excluding certain small self-administered health plans); managed care organizations; ERISA-covered health benefit plans; government health plans; all health care clearinghouses; and all health care providers that choose to submit or receive these transactions electronically.
Contains all required data elements needed to process and pay the claim (e.g., valid diagnosis and procedure/service codes, modifiers, and so on.
A set of supporting documentation or information associated with a health care claim or patient encounter.
Coordination of benefits (COB)
A provision in group health insurance policies intended to keep multiple insurers from paying benefits covered by other policies; it also specifies that coverage will be provided in a specific sequence when more than one policy covers the claim.
Involves sorting claims upon submission to collect and verify information about the patient and the provider.
When the claim is compared to payer edits and the patients health plan benefits to make certain verifications.
Any procedure or service reported on the claim that is not included on the master benefit.
Procedures and services provided to a patient without proper authorization from the payer, or that were not covered by a current authorization.
Common data file
An abstract of all recent claims filed on each patient.
The maximum amount the payer will allow for each procedure or service, according to the patient's policy.
The total amount of covered medical expenses a policyholder must pay each year out-of-pocket before the insurance company is obligated to pay any benefits.
The percentage the patient pays for covered services after the deductible has been met and the copayment has been paid.
Policyholder, or beneficiary
The person in whose name the insurance policy is issued.