National administrative code set that identifies the reasons for any differences, or adjustments, between the original provider charge for a claim or service and the payer’s payment for it. This code set is used in the X12 835 claim payment and remittance advice and the X12 837 claim transactions and is maintained by the Health Care Code Maintenance Committee.

Section or division in a life and health insurance company that processes insurance claims. In this division, claim examiners review claims submitted by medical providers, policy owners, or beneficiaries; verify the validity of claims; and authorize payment of benefits to either the provider or beneficiary of each claim.

Document with information, hard copy or electronic, related to a completed insurance claim that assists in validating the medical necessity or explains the medical service or procedure (e.g., operative report, discharge summary, invoice). When a claim attachment is included with a paper claim, Block 19 of the CMA-1500 insurance claim form is completed. When a claim is electronically transmitted, practice management and claims software include a data field that indicates that a paper claims attachment is included with the claim. Under the Health Insurance Portability and Accountability Act (HIPAA), electronic standards for claims attachments are being developed. Attachments may be structured (such as Certificates of Medical Necessity) or nonstructured (such as an operative report). Though attachments may be submitted separately, it is common to say the attachment was “submitted with the claim.”

Evaluation of insurance claims for duplicate medical services or billing that may be in excess of a normal pattern.

Unique multidigit number assigned by the Medi-Cal fiscal intermediary on a Treatment Authorization Request and used for reference when processing the request.

Insurance company’s attempt to streamline operations to contain and direct claim payments so that insurance premium funds are used efficiently.

Electronic examination of transmitted insurance claims for errors, conflicting code entries, and a match of diagnosis to medical service(s) provided. Also called edit check. See front-end edits.

Accumulation of information needed for payment or denial of an insurance claim.

Intentional misrepresentation by either providers or patients to obtain services, payment for services, or claim program eligibility. In insurance claims, fraudulent practices are intentionally double billing for the same services, reporting diagnoses and procedures to maximize payments, billing for services that were not performed, and so on.

In health insurance calculations, this is a value obtained from the expected percentage of insured individuals who will file claims and the number of claims they will file within a specific period of time. This rate is used to calculate average claim costs, which are used to establish premium rates.