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Glossary of Terms |
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These are the subsections in this section: |
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Accept Government Assignment |
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Address Type |
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Authorization of Payment |
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Billing Codes |
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Billing Entity |
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Billing Provider |
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Check Scope of Practice (also called Code Cross) |
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Claim Type |
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Current Condition Date |
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Diagnosis |
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Diagnosis Pointers |
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Diagnostician |
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First Occurrence |
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HMO |
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Insurance |
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Legacy Identification Number |
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Locations |
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Login |
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Medicare |
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Medicare Advantage Plan |
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Medicare Subcontractor |
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Modifier |
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New Mexico Gross Receipts Tax |
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Non-Diagnostician |
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NPI |
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Payer |
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Payer ID |
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Place of Service |
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PPO |
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Procedure |
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Provider |
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Provider Taxonomy |
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Provider Type |
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Referring Provider |
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Rendering Provider |
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Rendering Provider Legacy Identification Number |
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Rendering Provider NPI |
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Scope of Practice |
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Supervising Provider in Charge |
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Validation Rules |
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a. |
Accept Government Assignment |
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Medicare / Government Agency is a term used to describe an agreement between the health care provider and Medicare / government agency. Under assignment, the provider agrees to accept the Medicare / government-approved dollar amounts as the total charge amount allowable. |
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b. |
Address Type |
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Address Type identifies the address as Service Address, Billing Address, or both. |
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c. |
Authorization of Payment |
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The method used when a claimant directs that payment be made directly to the health care provider by the health plan. |
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d. |
Billing Codes |
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CPT® |
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Current Procedural Terminology – A standardized mechanism of reporting services using numeric codes as established and updated annually by the AMA. There is a manual that assigns five digit codes to medical services and procedures to standardize claims processing and data analysis. The coding system for physicians’ services developed by the CPT® Editorial Panel of the American Medical Association; it is the basis of the Medicare coding system for physicians services. It is also a medical code set of physician and other services, maintained and copyrighted by the American Medical Association (AMA) and has been adopted by the Secretary of HHS as the standard for reporting physician and other services on standard transactions. |
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HCPCS |
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Healthcare Common Procedure Coding System – These codes are for supplies, materials, and injections (i.e. bandages, rubber gloves, penicillin, etc.). They are reported in the same parts of insurance forms as CPT® codes (HCPSC as Level II CPT® codes). There are specialized HCPCS codes such as E, J, and L codes used for specific procedures or services |
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ABC Codes – Documentation |
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ABC codes are 5-character alphabetic symbols that identify services, remedies, and/or supplies. The use of these codes allows the provider to state the same CPT® / HCPCS code more than once on a single claim form because ABC codes allow providers to more accurately document the care rendered. |
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e. |
Billing Entity |
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The Billing Entity is the billing business name other than the Billing Provider. |
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f. |
Billing Provider |
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The Billing Provider is the party responsible for accurately documenting all necessary patient and provider data in order to submit claims for reimbursement. |
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g. |
Check Scope of Practice (also called a Code Cross) |
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ZipClaims uses information mapping HIPPA mandated codes to ABC codes that more accurately or specifically describe the coded procedures. The mapping is designed so that users can bill with any HIPPA mandated code set while also more accurately and precisely documenting care using ABC codes.
Subscribers can choose the code that is most likely to result in reimbursement and simultaneously document with ABC codes to assure truthful and accurate documentation of care. Results returned by the Check Scope of Practice function are directly related to each practitioner type’s state statutes and regulations.
When using Check Scope of Practice validation, the code cross will return all codes that could be utilized by the selected practitioner. Each code is marked as In Scope, Training Required, and Out of Scope. See the table supported practitioner types.
| Acupuncturist/Doctor of Oriental Medicine |
Naturopath |
| Chiropractor or Doctor of Chiropractic |
Nurse Midwife |
| Christian Science Practitioner |
Nurse Practitioner (all specialties) |
| Clinical Nurse Specialist |
Nutritionist* |
| Clinical Social Worker* |
Occupational Therapist* |
| Direct-Entry Midwife |
Pharmacist* |
| Doctor of Osteopathy |
Physical Therapist* |
| Licensed Practical Nurse |
Physician Assistant |
| Licensed Professional Counselor* |
Psychologist, doctorate* |
| Marriage and Family Therapist* |
Reflexologist |
| Massage Therapist and Bodyworker |
Registered Dietician* |
| Medical Doctor (all specialties) |
Registered Nurse |
| Naprapath |
Spiritual Care Nurse |
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h. |
Claim Type |
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New Claim – An original claim, first time sent to the payer.
Corrected Claim – An original claim changed to include new or edited information.
Replacement Claim – A claim that will be resubmitted with no changes. |
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i. |
Current Condition Date |
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Current Condition Date is the date of the onset of symptoms, diagnoses, and/or treatment. |
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j. |
Diagnosis – ICD-9 |
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Diagnosis – This is the conclusion reached through the process of identifying a medical condition or disease by its signs, symptoms, and from the results of various diagnostic procedures. The provider should consider the patient in his/her “well” context rather than simply as a walking medical condition. This entails assessing the socio-political context of the patient (family, work, stress, beliefs), in addition to the patient's physical body, as this often offers vital clues to the patient's condition and its management.
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM, ICD-10-CM) – This is the universal coding method used to document the incidence of disease, injury, mortality, and illness. It is a diagnosis and procedure classification system designed to facilitate the collection of uniform and comparable health information. The ICD-9-CM was issued in 1979. This system is used to group patients into DRGs, prepare hospital and physician billings, and prepare cost reports. Classification is based on the diagnosis and codified into six digit numbers.
Origin of Diagnosis – ZipClaims protects all practitioners, regardless of their ability to diagnose, by providing all-encompassing options for documenting the Origin of Diagnosis.
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Current diagnosis – The nature of the problem(s) or symptom(s) for which the patient is being treated. |
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Current Referral – The nature of the problem(s) or symptom(s) for which the patient is being referred to another provider of services. |
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Prior Referral – The previous referral for specific problem(s) or symptom(s). |
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Patient-Reported Complaint – The nature of the problem(s) or symptom(s) reported by the patient. |
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Preventive Care – A wellness visit; a state of physical and psychological well-being. |
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Diagnosis pointers |
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These pointers indicate which procedure was intended for the corresponding ICD-9 diagnosis code by inserting the number of the diagnosis’ position (i.e. 1, 2, 3, 4, etc.). The numbers are based on the degree of relevance to the symptom(s). |
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l. |
Diagnostician |
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A diagnostician is a provider who can legally formulate diagnoses, especially a physician or health care provider specializing in medical diagnostics. This authority is granted through legal statues and regulations based on state laws. |
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m. |
First Occurrence |
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The First Occurrence is the date when the patient or client had the same or similar illness. (This information is located in Field 15 on the 1500 health insurance claim form.) |
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n. |
HMO |
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Health Maintenance Organization – An entity that provides, offers, or arranges for coverage of designated health services needed by members for a fixed, prepaid premium. HMOs offer prepaid, comprehensive health coverage. |
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o. |
Insurance |
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Health Insurance provides coverage for medical visits to health care providers, emergency room, hospital stays, and other medical expenses.
Primary – An insurance policy, plan, or program that pays first on a claim for medical care.
Secondary – An insurance policy, plan, or program that pays second on a claim for medical care. |
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p. |
Legacy Identification Number |
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A Legacy Identification Number is a provider specific number designated by a particular payer. For example, provider specific identifiers are assigned to each provider enrolled with Medicare. |
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q. |
Locations |
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Billing – The location that provides billing for health care services rendered. The billing and service location can be the same location.
Service – The location at which health care services are provided. |
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r. |
Login |
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The Login is a pre-selected User Name and Password. |
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Medicare |
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Medicare is a federal program for the elderly and disabled, regardless of financial status. It is a US health insurance program for people aged 65 and over, for persons eligible for social security disability payments for two years or longer, and for certain workers and their dependents who need kidney transplantation or dialysis. |
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Medicare Advantage Plan |
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A plan offered by a private company that contracts with Medicare to provide an enrollee with all Medicare Part A and Part B benefits. Medicare Advantage Plans are HMOs, PPOs, Private Fee-for-Service Plans, and Special Needs Plans. When an individual is enrolled in a Medicare Advantage Plan, Medicare services are covered through the plans, and are not paid for under Original Medicare. |
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Medicare Subcontractor |
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Medicare claim processing subcontractors have been selected throughout the nation to provide regional area claims adjudication. |
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v. |
Modifier |
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A modifier is a two-character code added to a HIPPA mandated code that is used to help in the reimbursement process. For example, a modifier can be used to explain that a procedure not normally covered when billed on the same day as another is actually a separate and significant process, or that it is a rural health procedure that gets higher reimbursement. Up to four modifiers can be attached to each HIPPA mandated code; although in most cases only one or two are used. |
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w. |
New Mexico Gross Receipts Tax |
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Since ABC Coding Solutions, proprietor of ZipClaims, is owned and operated by Alternative Link Systems, Inc., a New Mexico based company, NM Gross receipts tax of 6.875% is charged to residents of New Mexico as determined by the billing zip code on the credit card used to purchase the ZipClaims subscription. |
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x. |
Non-diagnostician |
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A non-diagnostician is a provider who cannot legally formulate diagnoses for their patients. A non-diagnostician is not granted diagnostic authority by legal statues and regulations based on state laws. |
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y. |
NPI |
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National Provider Identifier – This is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS). The NPI has replaced the unique provider identification number (UPIN) as the required identifier for Medicare services, and will be used by other payers, including commercial healthcare insurers. The transition to the NPI was mandated as part of the Administrative Simplifications portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and CMS began issuing NPIs in October 2006. HIPAA covered entities such as providers completing electronic transactions, healthcare clearinghouses, and large health plans were required by regulation to use only the NPI to identify covered healthcare providers by May 23, 2007. Small health plans have one additional year to comply.
If you have not applied for your NPI, click here to complete the application. Processing time for online applications usually takes from one to three business days. Paper applications will take longer to process. |
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z. |
Payer |
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The public or private organization that is responsible for payment for health care expenses. Payers may be insurance companies, health plans, or third party administrators. |
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aa. |
Payer ID |
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A Payer ID is the identification number assigned to an insurance company or health plan so claims can be sent electronically. The Payer ID can also be referred to as an Electronic PIN. |
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bb. |
Place of Service |
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List of location types (i.e. Birthing Center, Office, Outpatient Facility, etc.) that are required to submit either electronic or paper claims. |
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cc. |
PPO |
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Preferred Provider Organization – A PPO is some combination of hospitals, physicians, and other practitioners that agrees to render particular services to a group of people, perhaps under contract with a private insurer. It is also a health care delivery system that contracts with providers of medical care to provide services at discounted fees to members. |
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dd. |
Procedure |
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A procedure is a course of action intended to achieve a positive result in the treatment of a patient. |
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ee. |
Provider |
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In terms of health care, provider refers to a hospital, practitioner, or doctor who "provides" care. |
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ff. |
Provider Taxonomy |
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Provider Taxonomy is a collection of unique alphanumeric codes, ten characters in length. The code set is structured into three distinct "Levels" including Provider Type, Classification, and Area of Specialization. It allows a single provider to identify their specialty category. Providers may have one or more than one value associated to them. |
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gg. |
Provider Type |
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Provider Type refers to the three options available: Rendering, Billing, and Referring. |
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hh. |
Referring Provider |
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A Referring Provider is the practitioner that referred the patient to a specialist/practitioner for a specific procedure/condition. |
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Rendering Provider |
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A Rendering / Performing Provider is the practitioner who treats and/or examines the patient. |
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Rendering Provider Legacy ID |
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The Legacy Identification Number of the Rendering Provider. |
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Rendering Provider NPI |
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The NPI (National Provider Identifier) of the Referring Provider. |
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ll. |
Scope of Practice |
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Scope of Practice consists of the statutes and regulations that specify the training required and allowable practices of each provider type. The statutes and regulations are mandated within each state for each practitioner type. Currently, seventeen different practitioners’ scope of practice and training requirements are provided within ZipClaims. Additional practitioners’ scope of practice is currently being developed. |
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mm. |
Supervising Provider in Charge |
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The Supervising Provider in Charge is the overseeing practitioner, if applicable. |
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nn. |
Validation Rules |
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ZipClaims uses Validation Rules as protection for all paper and electronic claims. Validation Rules check to ensure that all required fields have been completed prior to claim submission. |
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