Billing Glossary for Behavioral Health: 783 Insurance and Billing Terms Defined
Plain-English definitions of the billing, credentialing, claims, and payer terms that mental health practices run into every day. Each entry in this billing terms glossary shows why the term matters, an example, related terms, and a source.
In this glossary
- 783 terms in 21 sections
- Written for psychotherapists and psychiatrists
- Source organization linked on every entry
- Time-sensitive and payer-specific items flagged
- Search, A–Z, section and payer filters
What is a behavioral health billing glossary?
A behavioral health billing glossary is a reference list that defines the terms payers, clearinghouses, and billing teams use, so providers and staff read remittances, denial letters, and contracts the same way. This billing terms glossary is built for mental and behavioral health practices, and it serves both psychotherapists and psychiatrists.
What is the difference between a claim denial and a claim rejection?
A rejected claim never entered the payer's review because of a format or data error, so you fix it and resubmit it. A denied claim was reviewed and refused, so you appeal it or correct it under the payer's rules. Rejections come back from the clearinghouse or the payer's front end. Denials come back on the remittance advice with reason codes.
Three rule sets, kept separate: private-payer rules, Medicare and Medicaid rules, and state law often differ. Each entry is labeled General, Private payer, Medicare, or Medicaid (state-specific). When a rule varies by state or by payer, the entry says so. Confirm the current rule with the payer before you rely on it.
How to read an entry
Every entry follows the same six-part format, so you can scan quickly.
Definition
A plain-language explanation using industry-standard terms.
Why it matters
What the term changes in billing, compliance, payment, or credentialing.
Illustrative example
A made-up billing scenario that shows how the term works. It is not a real payer result.
Related terms
Links to connected entries so you can keep reading.
Reference source
The organization or payer whose guidance backs the entry.
Categories
The sections the term belongs to, plus a rule-set label.
Entries marked "Verify" depend on the payer, the plan, or the state. Entries marked "Time-sensitive" can change on a set schedule or by new rules. Check the source before you rely on them.
Written for both psychotherapists and psychiatrists
Most terms apply to every behavioral health practice. Where the two differ, the entry says so.
Psychotherapists
Start with the time-based psychotherapy codes, credentialing and enrollment, eligibility, superbills, and denials. Prescriber-only terms are marked.
Psychiatrists
Start with E/M codes and psychotherapy add-on codes, modifier 25, e-prescribing and EPCS, DEA registration, and prior authorization. Therapist-only terms are marked.
Sections
Browse the glossary by section
Pick a section, or search all terms in the billing terms glossary below.
- Credentialing & Enrollment 58
- Contracting & Network Management 22
- Claims Processing 172
- Eligibility & Benefits 75
- Payment & Reimbursement 61
- Denials & Appeals 46
- Audits & Compliance 115
- Behavioral Health Specific Terms 148
- CPT, E/M & HCPCS Code Entries 54
- Telehealth Terms 23
- Revenue Cycle Metrics 44
- EDI & Clearinghouse Terms 63
- BCBS, UHC & Commercial Payer Terms 54
- Medicare & Medicaid Terms 145
- Value-Based Care Terminology 23
- Prior Authorization Terminology 22
- Quality & Risk Adjustment Terms 34
- EHR & Healthcare Technology Terms 54
- Provider Data Management Terms 26
- Patient Financial Responsibility Terms 35
- AI & Healthcare Automation Terms 12
Find a term
A
- A/R Aging
- A/R Follow-Up
- AAPC
- Ability Network
- Accountable Care Organization (ACO)
- Accountable Care Partnership Plan (ACPP)
- Accounting of Disclosures
- Accounts Receivable (A/R)
- Accreditation
- Add-On Code
- Additional Documentation Request (ADR)
- Adjudication
- Administrative Adjustment
- Administrative Law Judge (ALJ) Hearing
- Administrative Services Only (ASO)
- Advance Beneficiary Notice (ABN)
- AdvancedMD
- Adverse Benefit Determination
- Aetna
- Age of Majority (Healthcare)
- AHIMA
- AI Coding Assistant
- AI Scribe
- Algorithmic Bias
- Allowed Amount
- Alpha Prefix
- Alternative Payment Model (APM)
- American Counseling Association Code of Ethics
- American Hospital Association (AHA)
- American Medical Association (AMA)
- American Psychiatric Association (APA)
- Anthem Blue Cross and Blue Shield
- Anti-Kickback Statute
- Appeal
- Appeal Deadline
- Appeal Success Rate
- Application Programming Interface (API)
- Applied Behavior Analysis (ABA)
- Assignment (Medicare)
- Assignment of Benefits (AOB)
- Associate Licensed Clinician
- athenahealth
- Attestation
- Audio-Only Telehealth
- Audit
- Audit Trail
- Authorization Date Range
- Authorization Denial
- Authorization Number
- Authorization Request
- Authorization to Access CAQH
- Authorized Units
- Automation
- Availity
B
- Bad Debt
- Balance Billing
- Batch Transaction
- Behavioral Health Billing
- Behavioral Health Care and Human Services Accreditation
- Behavioral Health Carve-In
- Behavioral Health Carve-Out
- Behavioral Health Integration (BHI)
- Behavioral Health Parity Complaint
- Benefit Exhaustion
- Benefit Verification
- Billed Charge
- Billing Provider
- Birthday Rule
- Blue Cross Blue Shield Association (BCBSA)
- Blue Cross Blue Shield Licensee
- Blue Shield of California
- BlueCard Program
- Box 1 (Type of Coverage)
- Box 10 (Condition Related To)
- Box 11 (Insured's Policy, Group, or FECA Number)
- Box 11d (Another Health Benefit Plan)
- Box 12 (Patient or Authorized Person's Signature)
- Box 13 (Insured's or Authorized Person's Signature)
- Box 14 (Date of Current Illness, Injury, or Pregnancy)
- Box 17 (Name of Referring Provider or Other Source)
- Box 19 (Additional Claim Information)
- Box 1a (Insured's ID Number)
- Box 21 (Diagnosis or Nature of Illness or Injury)
- Box 22 (Resubmission and Original Reference Number)
- Box 23 (Prior Authorization Number)
- Box 24A (Dates of Service)
- Box 24B (Place of Service)
- Box 24C (EMG)
- Box 24D (Procedures, Services, or Supplies)
- Box 24E (Diagnosis Pointer)
- Box 24F (Charges)
- Box 24G (Days or Units)
- Box 24H (EPSDT/Family Plan)
- Box 24I (ID Qualifier)
- Box 24J (Rendering Provider ID)
- Box 25 (Federal Tax ID Number)
- Box 26 (Patient's Account No.)
- Box 27 (Accept Assignment)
- Box 28 (Total Charge)
- Box 29 (Amount Paid)
- Box 31 (Signature of Physician or Supplier)
- Box 32 (Service Facility Location Information)
- Box 33 (Billing Provider Information and Phone Number)
- Box 4 (Insured's Name)
- Box 6 (Patient Relationship to Insured)
- Box 9 (Other Insured's Information)
- Breach Notification Rule
- Brief Emotional or Behavioral Assessment (96127)
- Bright Health
- Bundled Payment
- Bundling
- Business Associate
- Business Associate Agreement (BAA)
C
- CAHPS
- Calendar Year Deductible
- Cancellation Rate
- Capitation
- CAQH CORE
- CAQH ProView
- CAQH ProView Data Sharing
- CARC (Claim Adjustment Reason Code)
- Card on File
- Care Gap
- Care Management
- Care Management Organization (CMO)
- CareFirst
- Carelon Behavioral Health
- Category I CPT Code
- Category II CPT Code
- Category III CPT Code
- Centene
- CERT (Comprehensive Error Rate Testing)
- Certified Community Behavioral Health Clinic (CCBHC)
- Change Healthcare
- Charge Capture
- Charge Lag
- CHIP (Children's Health Insurance Program)
- Cigna Healthcare
- Civil Monetary Penalties (CMP)
- Claim
- Claim Attachment
- Claim Denial
- Claim Form
- Claim Frequency Code
- Claim Rejection
- Claim Scrubbing
- Claim Status
- Claim.MD
- Clean Claim
- Clean Claim Rate
- Clearinghouse
- Clearinghouse Enrollment
- Clearinghouse Outage Contingency
- Clearinghouse Rejection
- Clinical Psychologist
- Clinical Psychologist (Medicare)
- Clinical Social Worker (Medicare)
- CMS (Centers for Medicare & Medicaid Services)
- CMS-1500
- CMS-855
- CMS-855I
- CMS-855R
- COBRA
- Code Crosswalk
- Coding Denial
- Coinsurance
- Collaborative Care Model (CoCM)
- Collections
- Community Mental Health Center (CMHC)
- Companion Guide
- Compliance Officer
- Compliance Program
- Concurrent Review
- Confidential Communications Request
- Connecticut Behavioral Health Partnership
- Continuity of Care
- Contracted Rate
- Contractual Adjustment
- Conversion Factor
- Coordination of Benefits (COB)
- Copay
- Copay Waiver
- Corporate Integrity Agreement (CIA)
- Corrected Claim
- Cost to Collect
- Counseling Compact
- Coverage Effective Date
- Coverage Termination Date
- Covered Entity
- CPT 90785
- CPT 90791
- CPT 90792
- CPT 90832
- CPT 90833
- CPT 90834
- CPT 90836
- CPT 90837
- CPT 90838
- CPT 90839
- CPT 90840
- CPT 90845
- CPT 90846
- CPT 90847
- CPT 90849
- CPT 90853
- CPT 96127
- CPT 96130
- CPT 96131
- CPT 96132
- CPT 96133
- CPT 96136
- CPT 96137
- CPT 96138
- CPT 96139
- CPT 99202
- CPT 99203
- CPT 99204
- CPT 99205
- CPT 99211
- CPT 99212
- CPT 99213
- CPT 99214
- CPT 99215
- CPT 99341
- CPT 99342
- CPT 99343
- CPT 99344
- CPT 99345
- CPT 99347
- CPT 99348
- CPT 99349
- CPT 99350
- CPT 99408
- CPT 99409
- CPT 99417
- CPT Assistant
- CPT Code
- CPT Code Descriptor
- CPT Editorial Panel
- Credentialing
- Credentialing Application Status
- Credentialing Committee
- Credentialing Software
- Credentialing Turnaround
- CredentialMyDoc
- Credible
- Credit Balance
- Crisis Psychotherapy (90839 / 90840)
- Crossover Claim
D
- Data Retention
- DataSpring (formerly CAQH)
- Date of Service (DOS)
- Days in A/R
- Days in Unbilled
- DEA Registration
- Deductible
- Deemed Status
- Delegated Credentialing
- Denial Letter
- Denial Management
- Denial Prevention
- Denial Rate
- Dependent
- Dependent Coverage to Age 26
- Designated Record Set
- Diagnosis Pointer
- Diagnostic Evaluation (90791 / 90792)
- Digital Mental Health Treatment
- Distant Site
- Documentation
- Downcoding
- DSM-5-TR
- Dual Eligible
- Dual Eligible Special Needs Plan (D-SNP)
- Duplicate Claim
E
- E-Prescribing (eRx)
- E/M Code
- EAP Authorization
- EAP Vendor
- ECHO Health
- eClinicalWorks
- Effective Date
- EFT Enrollment
- EHR (Electronic Health Record)
- Electroconvulsive Therapy (ECT)
- Electronic Data Interchange (EDI)
- Electronic Funds Transfer (EFT)
- Elevance Health
- Eligibility Denial
- Eligibility Verification
- Eligibility Verification Tool
- Emancipated Minor
- Employee Assistance Program (EAP)
- EMR (Electronic Medical Record)
- Encounter Data
- Encounter Form
- Encryption
- Enrollment Follow-Up Call
- EPCS
- Epic
- EPO (Exclusive Provider Organization)
- EPSDT
- ERISA
- Essential Health Benefits (EHB)
- Established Patient (CPT)
- Evernorth
- Evidence-Based Practice in Psychology (EBPP)
- Experian Health
- Explanation of Benefits (EOB)
- Explanation of Payment (EOP)
- External Review
F
- Face-to-Face Time
- Facility Rate
- False Claims Act
- Family Psychotherapy (90846 / 90847)
- Federal Medical Assistance Percentage (FMAP)
- Federal Poverty Level (FPL)
- Federally Qualified Health Center (FQHC)
- Fee Schedule
- Fee-for-Service (FFS)
- FHIR
- Financial Hardship Policy
- FinThrive
- First Pass Resolution Rate (FPRR)
- Florida Blue
- Florida Statewide Medicaid Managed Care (SMMC)
- Frequency Limit
- Front-End Edit
- FSA (Flexible Spending Account)
- Fully Insured Plan
G
- GAD-7
- Gap Exception
- Gatekeeper
- Generative AI
- Geographic Practice Cost Index (GPCI)
- Georgia Families
- Georgia Pathways
- Ghost Network
- Gold Carding
- Good Faith Estimate (GFE)
- Grace Period (Coverage)
- Greenway Health
- Gross Collection Rate (GCR)
- Group Code CO
- Group Code OA
- Group Code PI
- Group Code PR
- Group Enrollment
- Group NPI
- Group Number
- Group Psychotherapy (90853)
- Guarantor
H
- H0031
- H2015
- H2017
- HCPCS (Healthcare Common Procedure Coding System)
- HCPCS G0318
- HCPCS G0396
- HCPCS G0397
- HCPCS G0442
- HCPCS G0443
- HCPCS G0444
- HCPCS G2211
- HCPCS G2212
- HCSC (Health Care Service Corporation)
- HDHP (High-Deductible Health Plan)
- Health First Colorado
- HEDIS
- HFMA (Healthcare Financial Management Association)
- HHS (Department of Health and Human Services)
- Hierarchical Condition Category (HCC)
- Highmark
- HIPAA
- HIPAA Authorization
- HIPAA Privacy Rule
- HIPAA Security Rule
- HIPAA Transaction Standards
- HITECH Act
- HL7
- HMO (Health Maintenance Organization)
- Home and Community-Based Services (HCBS)
- Home Plan
- Horizon Blue Cross Blue Shield of New Jersey
- Host Plan
- HRSA
- HSA (Health Savings Account)
- Human in the Loop
- Humana
I
- ICANotes
- ICD-10-CM
- Illinois HealthChoice
- In Loco Parentis
- In-Home Therapy
- In-Network
- In-Person Requirement (Medicare Mental Health)
- Incident-To Billing
- Independence Blue Cross
- Indian Health Service (IHS)
- Information Blocking
- Informed Consent
- Initial Authorization
- Initial Credentialing
- InstaMed
- Institutions for Mental Diseases (IMD) Exclusion
- Insurance Card
- InSync
- Intensive Outpatient Program (IOP)
- Interactive Complexity (90785)
- Internal Appeal
- Internal Control Number (ICN)
- Interoperability
K
L
- LEIE (List of Excluded Individuals/Entities)
- Letter of Medical Necessity
- Level of Care
- Licensed Professional Counselor (LPC)
- Licensure Compact
- Limited English Proficiency (LEP)
- Limiting Charge
- Linking a Provider to a Group
- Local Coverage Article (LCA)
- Local Coverage Determination (LCD)
- Long-Acting Injectable (LAI) Administration
M
- MAC Jurisdiction
- Machine Learning in Revenue Cycle
- MACRA
- Magellan Health
- Malpractice Insurance (Professional Liability)
- Managed Behavioral Health Organization (MBHO)
- Marketplace Plan
- Marriage and Family Therapist (Medicare)
- MassHealth
- Measurement-Based Care
- Measurement-Based Care (Joint Commission)
- Medicaid
- Medicaid Carve-Out
- Medicaid Expansion
- Medicaid Fee Schedule
- Medicaid HCPCS Code
- Medicaid Health Home
- Medicaid ID
- Medicaid Managed Care Organization (MCO)
- Medicaid Redetermination
- Medicaid Rehabilitation Option
- Medicaid Spend-Down
- Medicaid State Plan
- Medicaid Work Requirements
- Medical Billing Company
- Medical Decision Making (MDM)
- Medical Loss Ratio (MLR)
- Medical Necessity
- Medical Necessity Criteria
- Medical Record Audit
- Medically Unlikely Edit (MUE)
- Medicare
- Medicare Administrative Contractor (MAC)
- Medicare Advantage
- Medicare Appeals Council
- Medicare Beneficiary Identifier (MBI)
- Medicare Benefit Policy Manual
- Medicare Claims Processing Manual
- Medicare Coverage Database (MCD)
- Medicare Enrollment (PECOS)
- Medicare Opt-Out Affidavit
- Medicare Part A
- Medicare Part B
- Medicare Part B Deductible and Coinsurance
- Medicare Part D
- Medicare Physician Fee Schedule (MPFS)
- Medicare Physician Fee Schedule Look-Up Tool
- Medicare Savings Programs
- Medicare Secondary Payer (MSP)
- Medicare Shared Savings Program (MSSP)
- Medicare Summary Notice (MSN)
- Medicare Telehealth Services List
- Medicare Timely Filing
- Medication Management
- Medication-Assisted Treatment (MAT)
- Medigap
- MedTrainer
- Member ID
- Mental Health Counselor (Medicare)
- Mental Health Parity (MHPAEA)
- MGMA (Medical Group Management Association)
- MHPAEA Comparative Analysis
- Midpoint Rule (Timed Codes)
- Minimum Necessary
- Minor Consent Law
- MIPS (Merit-Based Incentive Payment System)
- MLN (Medicare Learning Network)
- Mobile Crisis Services
- Modified Adjusted Gross Income (MAGI)
- Modifier
- Modifier 25
- Modifier 59
- Modifier 93
- Modifier AH
- Modifier AJ
- Modifier FQ
- Modifier GT
- Modifier HN
- Modifier HO
- Modifier HP
- Modio Health
- Molina Healthcare
- Multi-Factor Authentication (MFA)
N
- NAACOS
- National Coverage Determination (NCD)
- National Patient Safety Goals (NPSG)
- NCCI Edits
- NCPDP
- NCQA
- Net Collection Rate (NCR)
- Netsmart
- Network Adequacy
- Network Rental (PPO Repricing)
- Network Termination
- Neuropsychological Testing
- New Patient (CPT)
- NextGen
- No Surprises Act
- No-Show Fee
- No-Show Rate
- Non-Facility Rate
- Non-Participating Provider (Non-PAR)
- Non-Quantitative Treatment Limitation (NQTL)
- North Carolina Medicaid Managed Care
- Notice of Privacy Practices (NPP)
- NPI (National Provider Identifier)
- NPPES
- NPSG.15.01.01 Suicide Risk Reduction
- NQF (National Quality Forum)
- NUBC (National Uniform Billing Committee)
- NUCC (National Uniform Claim Committee)
- NUCC 1500 Claim Form Instruction Manual
- NY Medicaid Managed Care
O
- OCR (Office for Civil Rights)
- Office Ally
- Offset
- OIG (Office of Inspector General)
- OIG General Compliance Program Guidance
- OIG Self-Disclosure Protocol
- OIG Work Plan
- Open Panel
- Opioid Treatment Program (OTP)
- Opt-Out (Medicare)
- Optum
- Optum Pay
- Oracle Health
- Originating Site
- Oscar Health
- Out-of-Network (OON)
- Out-of-Pocket Maximum
- Overpayment
P
- Paper Check Payment
- Parity Complaint
- Partial Hospitalization Program (PHP)
- Participating Provider (PAR)
- Participation Agreement
- Patient A/R
- Patient Control Number (PCN)
- Patient Portal
- Patient Refund
- Patient Responsibility
- Patient Statement
- Pay for Performance (P4P)
- Payer ID
- Payer Mix
- Payer of Last Resort
- Payer Portal
- Payment Address
- Payment Dispute
- Payment Plan
- Payment Platform
- Payment Posting
- PaySpan
- Peer Review
- Peer Support Services
- Peer-to-Peer Review
- Pended Claim
- Per Member Per Month (PMPM)
- Personal Representative (HIPAA)
- PHQ-9
- Place of Service (POS)
- Place of Service 02
- Place of Service 10
- Place of Service 11
- Place of Service 12
- Plan Year
- POS Plan (Point-of-Service Plan)
- Post-Payment Review
- PPO (Preferred Provider Organization)
- Practice Fusion
- Practice Management System (PMS)
- Pre-Payment Review
- Prepaid Ambulatory Health Plan (PAHP)
- Prepaid Inpatient Health Plan (PIHP)
- Presumptive Eligibility
- Primary Diagnosis
- Primary Insurance
- Primary Source Verification (PSV)
- Prior Authorization
- Prior Authorization API
- Private Contract
- Productivity Metrics
- Progress Note
- Prolonged Service
- Prominence Health Plan
- Prompt Pay Law
- Proof of Timely Filing
- Protected Health Information (PHI)
- Provider Data Accuracy
- Provider Directory
- Provider Enrollment Specialist
- Provider Taxonomy Mismatch
- Psychiatric Nurse Practitioner (PMHNP)
- Psychiatrist
- Psychological Testing
- Psychotherapist
- Psychotherapy Add-On Code
- Psychotherapy Notes
- Psychotherapy Time Ranges
- Public Health Emergency (PHE)
Q
R
- RADV (Risk Adjustment Data Validation)
- RARC (Remittance Advice Remark Code)
- RCM Platform
- Real-Time Transaction
- Reasonable and Necessary
- Reassignment of Benefits (Medicare)
- Reconsideration
- Recoupment
- Recovery Audit Contractor (RAC)
- Recredentialing
- Redetermination
- Referral
- Referring Provider
- Refund Request
- Regional Accountable Entity (RAE)
- Rejection Report
- Relative Value Unit (RVU)
- RelayHealth
- Remittance Advice (ERA)
- Remote Patient Monitoring (RPM)
- Rendering Provider
- Replacement Claim
- Research-Supported Psychological Treatment
- Residential Treatment
- Retro Authorization
- Retroactive Denial
- Retroactive Effective Date
- Retroactive Eligibility
- Retrospective Review
- Revenue Cycle Management (RCM)
- Revenue Integrity Solution
- Revenue Leakage
- RevSpring
- Right of Access (HIPAA)
- Risk Adjustment
- Risk Adjustment Factor (RAF)
- Robotic Process Automation (RPA)
- Role-Based Access Control (RBAC)
- Root Cause Analysis
- Roster
- Roster Validation
- Rural Health Clinic (RHC)
- RVS Update Committee (RUC)
S
- SAM Exclusions
- SAMHSA
- SBIRT
- Scope of Practice
- Screening
- Secondary Insurance
- Section 1557 (Nondiscrimination in Health Programs)
- Section 1915(b) Waiver
- Section 1915(c) Waiver
- Section 1915(i) State Plan HCBS
- Security Risk Analysis
- Self-Funded Plan
- Self-Pay
- Sentinel Event
- Serious Mental Illness (SMI)
- Shared Savings
- Signature on File (SOF)
- Significant, Separately Identifiable E/M
- SimplePractice
- Single Case Agreement (SCA)
- Sliding Scale
- Social Determinants of Health (SDOH)
- Special Needs Plan (SNP)
- SSI Group
- Star Ratings
- Stark Law
- State Fair Hearing
- State Insurance Department
- State License
- State Mandate
- State Medicaid Enrollment
- State Plan Amendment (SPA)
- Step Therapy
- Submitter ID
- Subscriber
- Substance Use Disorder Treatment
- Suicide Risk Screening
- Superbill
- Supervising Provider
T
- T-MSIS
- T1017
- Takeback
- Targeted Case Management (TCM)
- Targeted Probe and Educate (TPE)
- Tax Identification Number (TIN)
- Taxonomy Code
- Tebra
- TEFCA
- Telehealth
- Telehealth Flexibilities
- Telehealth Licensure
- Telehealth Modifier 95
- Telehealth Platform
- Telepsychiatry
- TennCare
- Tertiary Insurance
- Texas Medicaid STAR
- The Joint Commission
- TherapyNotes
- Third-Party Administrator (TPA)
- Third-Party Liability (TPL)
- Timely Filing
- Timely Filing Denial
- Total Time on the Date of the Encounter
- Tracer Methodology
- Transcranial Magnetic Stimulation (TMS)
- Treatment Plan
- Treatment, Payment, and Health Care Operations (TPO)
- TRICARE
- TriZetto
- Type 1 NPI
- Type 2 NPI
U
V
W
X
Z
#
- 1115 Waiver
- 270/271 Eligibility Transaction
- 276/277 Claim Status Transaction
- 277CA Claim Acknowledgment
- 278 Prior Authorization Transaction
- 42 CFR Part 2
- 60-Day Overpayment Rule
- 834 Enrollment Transaction
- 835 Electronic Remittance Advice
- 837I
- 837P
- 988 Suicide and Crisis Lifeline
- 999 Implementation Acknowledgment
Recently updated
- 60-Day Overpayment Rule
Audits & Compliance · reviewed 9/30/26 - Age of Majority (Healthcare)
Audits & Compliance · reviewed 9/30/26
Audits & Compliance · reviewed 9/30/26
Audits & Compliance · reviewed 9/30/26
Audits & Compliance · reviewed 9/30/26
Audits & Compliance · reviewed 9/30/26
Audits & Compliance · reviewed 9/30/26
Audits & Compliance · reviewed 9/30/26
Audits & Compliance · reviewed 9/30/26
Audits & Compliance · reviewed 9/30/26- Audio-Only Telehealth
Telehealth Terms · reviewed 9/30/26 - Behavioral Health Carve-In
BCBS, UHC & Commercial Payer Terms · reviewed 9/30/26 - Care Management Organization (CMO)
Medicare & Medicaid Terms · reviewed 9/30/26 - Conversion Factor
Payment & Reimbursement · reviewed 9/30/26 - Counseling Compact
Credentialing & Enrollment · reviewed 9/30/26 - Digital Mental Health Treatment
Telehealth Terms · reviewed 9/30/26 - Federal Medical Assistance Percentage (FMAP)
Medicare & Medicaid Terms · reviewed 9/30/26 - Federal Poverty Level (FPL)
Eligibility & Benefits · reviewed 9/30/26 - Georgia Families
Medicare & Medicaid Terms · reviewed 9/30/26 - Georgia Pathways
Medicare & Medicaid Terms · reviewed 9/30/26 - HCPCS G2211
CPT, E/M & HCPCS Code Entries · reviewed 9/30/26 - HCPCS G2212
CPT, E/M & HCPCS Code Entries · reviewed 9/30/26 - Illinois HealthChoice
Medicare & Medicaid Terms · reviewed 9/30/26 - In-Person Requirement (Medicare Mental Health)
Telehealth Terms · reviewed 9/30/26 - MassHealth
Medicare & Medicaid Terms · reviewed 9/30/26 - Medicaid Expansion
Medicare & Medicaid Terms · reviewed 9/30/26 - Medicaid Fee Schedule
Payment & Reimbursement · reviewed 9/30/26 - Medicaid Redetermination
Medicare & Medicaid Terms · reviewed 9/30/26 - Medicaid Work Requirements
Medicare & Medicaid Terms · reviewed 9/30/26 - Medicare Part B Deductible and Coinsurance
Medicare & Medicaid Terms · reviewed 9/30/26 - Medicare Physician Fee Schedule Look-Up Tool
Medicare & Medicaid Terms · reviewed 9/30/26 - Medicare Telehealth Services List
Telehealth Terms · reviewed 9/30/26 - Mental Health Parity (MHPAEA)
Audits & Compliance · reviewed 9/30/26 - MHPAEA Comparative Analysis
Audits & Compliance · reviewed 9/30/26 - Modifier FQ
Telehealth Terms · reviewed 9/30/26 - National Patient Safety Goals (NPSG)
Quality & Risk Adjustment Terms · reviewed 9/30/26 - Non-Quantitative Treatment Limitation (NQTL)
Audits & Compliance · reviewed 9/30/26 - North Carolina Medicaid Managed Care
Medicare & Medicaid Terms · reviewed 9/30/26 - NPSG.15.01.01 Suicide Risk Reduction
Quality & Risk Adjustment Terms · reviewed 9/30/26 - NUCC 1500 Claim Form Instruction Manual
Claims Processing · reviewed 9/30/26 - NY Medicaid Managed Care
Medicare & Medicaid Terms · reviewed 9/30/26 - OIG Work Plan
Audits & Compliance · reviewed 9/30/26 - Originating Site
Telehealth Terms · reviewed 9/30/26 - Prior Authorization API
Prior Authorization Terminology · reviewed 9/30/26 - Public Health Emergency (PHE)
Telehealth Terms · reviewed 9/30/26 - Regional Accountable Entity (RAE)
Medicare & Medicaid Terms · reviewed 9/30/26 - Section 1557 (Nondiscrimination in Health Programs)
Audits & Compliance · reviewed 9/30/26 - Telehealth
Telehealth Terms · reviewed 9/30/26 - Telehealth Flexibilities
Telehealth Terms · reviewed 9/30/26 - Telepsychiatry
Telehealth Terms · reviewed 9/30/26
Acronyms
- A/R Accounts Receivable (A/R)
- AAPC AAPC
- ABA Applied Behavior Analysis (ABA)
- ABD Adverse Benefit Determination
- ABN Advance Beneficiary Notice (ABN)
- ACO Accountable Care Organization (ACO)
- ACPP Accountable Care Partnership Plan (ACPP)
- ADR Additional Documentation Request (ADR)
- AHA American Hospital Association (AHA)
- AHIMA AHIMA
- AKS Anti-Kickback Statute
- ALJ Administrative Law Judge (ALJ) Hearing
- AMA American Medical Association (AMA)
- AOB Assignment of Benefits (AOB)
- APA American Psychiatric Association (APA)
- API Application Programming Interface (API)
- APM Alternative Payment Model (APM)
- AR Accounts Receivable (A/R)
- ASO Administrative Services Only (ASO)
- BAA Business Associate Agreement (BAA)
- BCBSA Blue Cross Blue Shield Association (BCBSA)
- BCBSTX HCSC (Health Care Service Corporation)
- BHCHS Behavioral Health Care and Human Services Accreditation
- BHI Behavioral Health Integration (BHI)
- BHO Managed Behavioral Health Organization (MBHO)
- BSC Blue Shield of California
- C-SSRS Suicide Risk Screening
- CAC AI Coding Assistant
- CAHPS CAHPS
- CALOCUS Medical Necessity Criteria
- CAQH DataSpring (formerly CAQH)
- CARC CARC (Claim Adjustment Reason Code)
- CCBHC Certified Community Behavioral Health Clinic (CCBHC)
- CCN Veterans Affairs Community Care
- CERT CERT (Comprehensive Error Rate Testing)
- CF Conversion Factor
- CHIP CHIP (Children's Health Insurance Program)
- CIA Corporate Integrity Agreement (CIA)
- CMHC Community Mental Health Center (CMHC)
- CMO Care Management Organization (CMO)
- CMP Civil Monetary Penalties (CMP)
- CMS CMS (Centers for Medicare & Medicaid Services)
- CMS-1450 UB-04 (CMS-1450)
- CMS-1500 Claim Form
- CMS-855 CMS-855
- CMS-855B CMS-855
- CMS-855I CMS-855
- CMS-855R CMS-855
- CMS-HCC Hierarchical Condition Category (HCC)
- CMS-R-131 Advance Beneficiary Notice (ABN)
- COB Coordination of Benefits (COB)
- COBRA COBRA
- CPT CPT Code
- CYD Calendar Year Deductible
- D-SNP Dual Eligible Special Needs Plan (D-SNP)
- DAR Days in A/R
- DCN Internal Control Number (ICN)
- DMHT Digital Mental Health Treatment
- DOI State Insurance Department
- DOS Date of Service (DOS)
- DRS Designated Record Set
- DSM DSM-5-TR
- DSM-5-TR DSM-5-TR
- E/M E/M Code
- EAP Employee Assistance Program (EAP)
- EBPP Evidence-Based Practice in Psychology (EBPP)
- ECHO ECHO Health
- ECT Electroconvulsive Therapy (ECT)
- EDI Electronic Data Interchange (EDI)
- EFT Electronic Funds Transfer (EFT)
- EHB Essential Health Benefits (EHB)
- EHR EHR (Electronic Health Record)
- EIN Tax Identification Number (TIN)
- EMG Box 24C (EMG)
- EMR EMR (Electronic Medical Record)
- EOB Explanation of Benefits (EOB)
- EOP Explanation of Payment (EOP)
- EPCS EPCS
- EPSDT Box 24H (EPSDT/Family Plan)
- ERA Remittance Advice (ERA)
- ERISA ERISA
- EST Research-Supported Psychological Treatment
- FCA False Claims Act
- FFS Fee-for-Service (FFS)
- FHIR FHIR
- FMAP Federal Medical Assistance Percentage (FMAP)
- FPL Federal Poverty Level (FPL)
- FPRR First Pass Resolution Rate (FPRR)
- FQHC Federally Qualified Health Center (FQHC)
- FSA FSA (Flexible Spending Account)
- G0318 HCPCS G0318
- G0396 HCPCS G0396
- G0397 HCPCS G0397
- G0442 HCPCS G0442
- G0443 HCPCS G0443
- G0444 HCPCS G0444
- G2211 HCPCS G2211
- G2212 HCPCS G2212
- GAD-7 GAD-7
- GCPG OIG General Compliance Program Guidance
- GCR Gross Collection Rate (GCR)
- GFE Good Faith Estimate (GFE)
- GPCI Geographic Practice Cost Index (GPCI)
- H0031 H0031
- H2015 H2015
- H2017 H2017
- HARP NY Medicaid Managed Care
- HCBS Home and Community-Based Services (HCBS)
- HCC Hierarchical Condition Category (HCC)
- HCFA-1500 CMS-1500
- HCI Illinois HealthChoice
- HCPCS HCPCS (Healthcare Common Procedure Coding System)
- HCSC HCSC (Health Care Service Corporation)
- HDHP HDHP (High-Deductible Health Plan)
- HEDIS HEDIS
- HFMA HFMA (Healthcare Financial Management Association)
- HHS HHS (Department of Health and Human Services)
- HIPAA HIPAA
- HITECH HITECH Act
- HL7 HL7
- HRSA HRSA
- HSA HSA (Health Savings Account)
- IBX Independence Blue Cross
- ICD-10 ICD-10-CM
- ICD-10-CM ICD-10-CM
- ICN Internal Control Number (ICN)
- IHS Indian Health Service (IHS)
- IMD Institutions for Mental Diseases (IMD) Exclusion
- IOP Intensive Outpatient Program (IOP)
- KP Kaiser Permanente
- KPI Key Performance Indicator (KPI)
- LAI Long-Acting Injectable (LAI) Administration
- LCA Local Coverage Article (LCA)
- LCD Local Coverage Determination (LCD)
- LCPC Licensed Professional Counselor (LPC)
- LCSW Psychotherapist
- LEIE LEIE (List of Excluded Individuals/Entities)
- LEP Limited English Proficiency (LEP)
- LLM Generative AI
- LMFT Psychotherapist
- LMHC Licensed Professional Counselor (LPC)
- LMN Letter of Medical Necessity
- LOA Single Case Agreement (SCA)
- LOC Level of Care
- LOCUS Medical Necessity Criteria
- LPC Licensed Professional Counselor (LPC)
- LPCC Licensed Professional Counselor (LPC)
- MA Medicare Advantage
- MAC Medicare Administrative Contractor (MAC)
- MACRA MACRA
- MAGI Modified Adjusted Gross Income (MAGI)
- MAP NY Medicaid Managed Care
- MAT Medication-Assisted Treatment (MAT)
- MBC Measurement-Based Care
- MBHO Behavioral Health Carve-Out
- MBI Medicare Beneficiary Identifier (MBI)
- MCD Medicare Coverage Database (MCD)
- MCG Medical Necessity Criteria
- MCO Medicaid Managed Care Organization (MCO)
- MDM Medical Decision Making (MDM)
- MFA Multi-Factor Authentication (MFA)
- MGMA MGMA (Medical Group Management Association)
- MHPAEA Mental Health Parity (MHPAEA)
- MIPS MIPS (Merit-Based Incentive Payment System)
- MLN MLN (Medicare Learning Network)
- MLR Medical Loss Ratio (MLR)
- MOUD Medication-Assisted Treatment (MAT)
- MPFS Medicare Physician Fee Schedule (MPFS)
- MSN Medicare Summary Notice (MSN)
- MSP Medicare Savings Programs
- MSSP Medicare Shared Savings Program (MSSP)
- MUE Medically Unlikely Edit (MUE)
- NAACOS NAACOS
- NCCI NCCI Edits
- NCD National Coverage Determination (NCD)
- NCPDP NCPDP
- NCQA NCQA
- NCR Net Collection Rate (NCR)
- NPP Notice of Privacy Practices (NPP)
- NPPES NPPES
- NPSG National Patient Safety Goals (NPSG)
- NPSGs National Patient Safety Goals (NPSG)
- NQF NQF (National Quality Forum)
- NQTL Non-Quantitative Treatment Limitation (NQTL)
- NSA No Surprises Act
- NUBC NUBC (National Uniform Billing Committee)
- NUCC NUCC (National Uniform Claim Committee)
- OCR OCR (Office for Civil Rights)
- OIG OIG (Office of Inspector General)
- OON Out-of-Network (OON)
- OTP Opioid Treatment Program (OTP)
- P2P Peer-to-Peer Review
- P4P Pay for Performance (P4P)
- PA Prior Authorization
- PAHP Prepaid Ambulatory Health Plan (PAHP)
- PAR Participating Provider (PAR)
- PCN Box 26 (Patient's Account No.)
- PE Presumptive Eligibility
- PECOS Medicare Enrollment (PECOS)
- PFS Medicare Physician Fee Schedule (MPFS)
- PHE Public Health Emergency (PHE)
- PHI Protected Health Information (PHI)
- PHP Level of Care
- PHQ-9 PHQ-9
- PIHP Prepaid Inpatient Health Plan (PIHP)
- PMHNP Psychiatric Nurse Practitioner (PMHNP)
- PMPM Capitation
- PMS Practice Management System (PMS)
- POS Place of Service (POS)
- PR Patient Responsibility
- PSV Primary Source Verification (PSV)
- PSYPACT Licensure Compact
- PWK Claim Attachment
- QIC Qualified Independent Contractor (QIC) Reconsideration
- QMB Qualified Medicare Beneficiary (QMB)
- QPP Quality Payment Program (QPP)
- RAC Recovery Audit Contractor (RAC)
- RAE Regional Accountable Entity (RAE)
- RAF Risk Adjustment Factor (RAF)
- RARC RARC (Remittance Advice Remark Code)
- RBAC Role-Based Access Control (RBAC)
- RCM Revenue Cycle Management (RCM)
- RHC Rural Health Clinic (RHC)
- ROI HIPAA Authorization
- RPA Robotic Process Automation (RPA)
- RPM Remote Patient Monitoring (RPM)
- RTC Residential Treatment
- RUC RVS Update Committee (RUC)
- RVU Relative Value Unit (RVU)
- SAMHSA SAMHSA
- SBIRT SBIRT
- SCA Single Case Agreement (SCA)
- SCHIP CHIP (Children's Health Insurance Program)
- SDOH Social Determinants of Health (SDOH)
- SDP OIG Self-Disclosure Protocol
- SMI Serious Mental Illness (SMI)
- SMMC Florida Statewide Medicaid Managed Care (SMMC)
- SNP Special Needs Plan (SNP)
- SOF Signature on File (SOF)
- SPA State Plan Amendment (SPA)
- SRA Security Risk Analysis
- STAR Texas Medicaid STAR
- T-MSIS T-MSIS
- T1017 T1017
- TCM Targeted Case Management (TCM)
- TEFCA TEFCA
- TIN Tax Identification Number (TIN)
- TJC The Joint Commission
- TMS Transcranial Magnetic Stimulation (TMS)
- TPA Third-Party Administrator (TPA)
- TPE Targeted Probe and Educate (TPE)
- TPL Third-Party Liability (TPL)
- TPO Treatment, Payment, and Health Care Operations (TPO)
- TRICARE TRICARE
- U&C Usual, Customary and Reasonable (UCR)
- UB-04 Claim Form
- UCR Usual, Customary and Reasonable (UCR)
- UHC UnitedHealthcare
- UM Utilization Review (UR)
- UPIC Unified Program Integrity Contractor (UPIC)
- UR Utilization Review (UR)
- URAC URAC
- USCDI USCDI
- VBC Value-Based Care
- VCC Virtual Credit Card (VCC)
- VOB Benefit Verification
- WEDI WEDI
- X12 X12
Terms by payer or program
Medicare (49)
- 60-Day Overpayment Rule
- Advance Beneficiary Notice (ABN)
- Assignment (Medicare)
- Clinical Psychologist (Medicare)
- Clinical Social Worker (Medicare)
- CMS-855I
- CMS-855R
- Deemed Status
- Dual Eligible Special Needs Plan (D-SNP)
- Federally Qualified Health Center (FQHC)
- Geographic Practice Cost Index (GPCI)
- HCPCS G0318
- HCPCS G0396
- HCPCS G0397
- HCPCS G0442
- HCPCS G0443
- HCPCS G0444
- HCPCS G2211
- HCPCS G2212
- Limiting Charge
- Local Coverage Article (LCA)
- Local Coverage Determination (LCD)
- MAC Jurisdiction
- Marriage and Family Therapist (Medicare)
- Medicare
- Medicare Administrative Contractor (MAC)
- Medicare Advantage
- Medicare Beneficiary Identifier (MBI)
- Medicare Benefit Policy Manual
- Medicare Claims Processing Manual
- Medicare Coverage Database (MCD)
- Medicare Opt-Out Affidavit
- Medicare Part A
- Medicare Part B
- Medicare Part B Deductible and Coinsurance
- Medicare Part D
- Medicare Physician Fee Schedule Look-Up Tool
- Medicare Savings Programs
- Medicare Summary Notice (MSN)
- Medicare Telehealth Services List
- Medicare Timely Filing
- Medigap
- Mental Health Counselor (Medicare)
- MLN (Medicare Learning Network)
- National Coverage Determination (NCD)
- Private Contract
- Reasonable and Necessary
- Rural Health Clinic (RHC)
- Special Needs Plan (SNP)
Medicaid (55)
- 1115 Waiver
- 60-Day Overpayment Rule
- Accountable Care Partnership Plan (ACPP)
- Box 24H (EPSDT/Family Plan)
- Care Management Organization (CMO)
- CHIP (Children's Health Insurance Program)
- Connecticut Behavioral Health Partnership
- Dual Eligible Special Needs Plan (D-SNP)
- EPSDT
- Federal Medical Assistance Percentage (FMAP)
- Federally Qualified Health Center (FQHC)
- Florida Statewide Medicaid Managed Care (SMMC)
- Georgia Families
- Georgia Pathways
- Health First Colorado
- Home and Community-Based Services (HCBS)
- HRSA
- Illinois HealthChoice
- Indian Health Service (IHS)
- Institutions for Mental Diseases (IMD) Exclusion
- MassHealth
- Medicaid
- Medicaid Carve-Out
- Medicaid Expansion
- Medicaid Fee Schedule
- Medicaid Health Home
- Medicaid Redetermination
- Medicaid Rehabilitation Option
- Medicaid Spend-Down
- Medicaid State Plan
- Medicaid Work Requirements
- Medicare Savings Programs
- Mobile Crisis Services
- Modified Adjusted Gross Income (MAGI)
- North Carolina Medicaid Managed Care
- NY Medicaid Managed Care
- Payer of Last Resort
- Peer Support Services
- Prepaid Ambulatory Health Plan (PAHP)
- Prepaid Inpatient Health Plan (PIHP)
- Presumptive Eligibility
- Regional Accountable Entity (RAE)
- Rural Health Clinic (RHC)
- SAMHSA
- Section 1915(b) Waiver
- Section 1915(c) Waiver
- Section 1915(i) State Plan HCBS
- Serious Mental Illness (SMI)
- State Fair Hearing
- State Plan Amendment (SPA)
- T-MSIS
- Targeted Case Management (TCM)
- TennCare
- Texas Medicaid STAR
- Third-Party Liability (TPL)
Commercial (1)
Blue Cross Blue Shield (14)
- Alpha Prefix
- Blue Cross Blue Shield Association (BCBSA)
- Blue Cross Blue Shield Licensee
- Blue Shield of California
- BlueCard Program
- CareFirst
- Florida Blue
- HCSC (Health Care Service Corporation)
- Highmark
- Home Plan
- Horizon Blue Cross Blue Shield of New Jersey
- Host Plan
- Independence Blue Cross
- Prominence Health Plan
UnitedHealthcare / Optum (2)
Aetna (1)
Cigna / Evernorth (2)
Anthem / Elevance (2)
Humana (1)
Centene / Molina / Wellcare / Magellan (4)
Kaiser Permanente (1)
TRICARE / VA (2)
EAP (3)
Keep reading
CPT & E/M Code GuideLink at launch
Codes, modifiers and place of service.
Denied & Rejected Claims Follow-Up and AppealsLink at launch
How MCM South works denials.
Electronic Claims SubmissionLink at launch
Clean claims and clearinghouse basics.
Insurance Verification & Eligibility ChecksLink at launch
Benefits and eligibility before the visit.
Insurance CredentialingLink at launch
Enrollment and credentialing explained.
Who We ServeLink at launch
Psychotherapists, psychiatrists, solo and group practices.
Frequency & Documentation RequirementsLink at launch
Session frequency and documentation.
Billing FAQ
Answers to common billing questions.
Billing glossary questions
What is a billing glossary, and who is it for?
It is a reference list of billing, credentialing, claims, and payer terms with plain-English definitions. It is for solo and group practice owners, the office managers and staff who bill day to day, and industry professionals who need citable definitions.
How current are the definitions?
Each entry links to its source organization, and time-sensitive entries are flagged so you can confirm the current rule. Payer and government rules change, so check the source or the payer before you rely on a definition for a claim or a contract.
Do the definitions apply the same way to every payer and state?
No. Private payers, Medicare, Medicaid, and state law can differ, and Medicaid is set state by state. Blue Cross Blue Shield is a federation of independent plans, so one plan’s rules do not apply to another by default. Entries say when a rule varies.
Does naming a company or product mean MCM South endorses it?
No. Company and product names appear for reference only. Naming one is not an endorsement or a partnership. Where MCM South has an affiliate relationship, the entry says so next to the name.
Is this legal or compliance advice?
No. This glossary is operational billing guidance. For anything with real financial or legal exposure, such as overpayments, audits, or contract disputes, talk to an attorney or a compliance officer.
Where the definitions come from
Each entry names the organization or payer whose guidance backs it. These are the federal, professional, and standards organizations used.
- CMS
- Medicare Learning Network
- Medicaid.gov
- HHS
- HHS OIG
- HHS OCR
- HRSA
- SAMHSA
- National Quality Forum
- American Psychiatric Association
- American Medical Association
- American Hospital Association
- HFMA
- MGMA
- NAACOS
- AHIMA
- AAPC
- WEDI
- DataSpring (formerly CAQH)
- NCQA
- The Joint Commission
- URAC
- NUBC
- NUCC
- HL7
- HL7 FHIR
- X12
- NCPDP
Company and product names appear for reference. Naming one is not an endorsement or partnership. Where MCM South has an affiliate relationship, the entry says so.
Operational billing guidance, not legal, clinical, or financial advice. Definitions are current as of the last review on 9/30/26. Reconfirm time-sensitive items with the source before you rely on them.
Can't pin down a billing term or a payer rule?
Tell us what you are seeing on your remittances or denial letters. We will point you to the right answer.