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Billing Terms Glossary

Clearinghouse Terms: Definitions for Therapists and Psychiatrists

These clearinghouse terms are defined in plain English for therapists and psychiatrists. EDI and clearinghouse terms describe how claims and payments move electronically. These definitions cover X12 transactions, payer IDs, rejections, and health data standards.

In this section

42 terms defined
Written for psychotherapists and psychiatrists
Source organization linked on every entry

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Quiet behavioral health practice office with a desk and armchairs, the setting for our clearinghouse terms glossary

270/271 Eligibility Transaction

General (all payers)

Also called: 270; 271; electronic eligibility inquiry

Definition: The pair of electronic transactions used to ask a payer about a member's eligibility (270) and receive the response (271).
Why it matters: Real-time checks reduce eligibility denials.
Illustrative example: A system sends a 270 and gets a 271 with copay details.

Reference source X12

Categories EDI & Clearinghouse TermsEligibility & Benefits

276/277 Claim Status Transaction

General (all payers)

Also called: 276; 277; electronic claim status

Definition: The pair of electronic transactions used to ask about a claim's status (276) and receive the response (277).
Why it matters: Automates status checks.
Illustrative example: A system checks claim status by 276.

Reference source X12

Categories EDI & Clearinghouse TermsClaims Processing

277CA Claim Acknowledgment

General (all payers)

Also called: 277CA; claim acknowledgement

Definition: An electronic response that tells the submitter whether a claim was accepted or rejected at a payer or clearinghouse level.
Why it matters: Provides proof of acceptance for timely filing.
Illustrative example: A 277CA shows the payer accepted the claim on a date.

Reference source X12

Categories EDI & Clearinghouse TermsClaims Processing

278 Prior Authorization Transaction

General (all payers)

Also called: 278; electronic authorization request

Definition: The standard transaction for health care service review and authorization requests and responses.
Why it matters: Used to automate authorization in some workflows.
Illustrative example: A system submits a 278 request.

Reference source X12

Categories EDI & Clearinghouse TermsPrior Authorization Terminology

834 Enrollment Transaction

General (all payers)

Also called: 834; benefit enrollment file

Definition: The standard transaction plans use to send enrollment and maintenance information.
Why it matters: Explains how plans get member data from employers.
Illustrative example: A payer receives an 834 from an employer.

Related terms Eligibility Verification Subscriber

Reference source X12

Categories EDI & Clearinghouse TermsEligibility & Benefits

835 Electronic Remittance Advice

General (all payers)

Also called: 835; ERA file

Definition: The electronic transaction that carries payment and adjustment details from a payer to a provider.
Why it matters: Enables auto-posting of payments.
Illustrative example: A practice imports an 835 to post payments.

Reference source X12

Categories EDI & Clearinghouse TermsPayment & Reimbursement

837I

General (all payers)

Also called: 837 institutional; electronic institutional claim

Definition: The electronic transaction for institutional claims, equivalent to the UB-04.
Why it matters: Facility-based programs use it.
Illustrative example: A residential program sends 837I claims.

Related terms UB-04 (CMS-1450)837P

Reference source X12

Categories EDI & Clearinghouse TermsClaims Processing

837P

General (all payers)

Also called: 837 professional; electronic professional claim

Definition: The electronic transaction for professional claims, equivalent to the CMS-1500.
Why it matters: Most therapy and psychiatry claims are sent as 837P.
Illustrative example: A clearinghouse transmits an 837P batch to a payer.

Related terms CMS-1500 837I Clearinghouse

Reference source X12

Categories EDI & Clearinghouse TermsClaims Processing

999 Implementation Acknowledgment

General (all payers)

Also called: 999; functional acknowledgment

Definition: An electronic acknowledgment that a file was received and passed or failed syntax checks.
Why it matters: Shows the file was technically received.
Illustrative example: A 999 shows a batch was accepted.

Reference source X12

Categories EDI & Clearinghouse Terms

Ability Network

General (all payers)

Also called: Ability; Ability clearinghouse

Definition: A health care technology company offering clearinghouse and revenue cycle connectivity. Listed for reference; not an endorsement or partnership.
Why it matters: Appears in payer connection lists.
Illustrative example: A practice connects to a payer through Ability.

Verify: confirm current ownership and offerings.

Related terms Clearinghouse Payer ID

Reference source Ability Network

Categories EDI & Clearinghouse Terms

Availity

General (all payers)

Also called: Availity Essentials; Availity portal

Definition: A health information network and portal used by many payers for eligibility, claims status, authorizations, and other transactions, and a clearinghouse. Listed for reference; not an endorsement or partnership.
Why it matters: Many payers direct providers to Availity for portal functions.
Illustrative example: A biller checks a member's eligibility and claim status through Availity.

Related terms Payer Portal Clearinghouse

Reference source Availity

Categories EDI & Clearinghouse Terms

Batch Transaction

General (all payers)

Also called: batch file; batch submission

Definition: A group of transactions sent together and processed on a schedule.
Why it matters: Common for claims; results return later.
Illustrative example: A clearinghouse sends a nightly batch.

Related terms Real-Time Transaction Clearinghouse

Reference source X12

Categories EDI & Clearinghouse Terms

CAQH CORE

General (all payers)

Also called: Committee on Operating Rules for Information Exchange; operating rules

Definition: A set of operating rules from DataSpring (formerly CAQH) for administrative transactions such as eligibility and claim status. They add detail on top of HIPAA transaction standards.
Why it matters: Explains why some payers return certain response times or data elements in eligibility checks.
Illustrative example: An eligibility response arrives in the format defined by the CORE rule.

Reference source DataSpring (formerly CAQH) · WEDI

Categories EDI & Clearinghouse TermsCredentialing & Enrollment

Change Healthcare

General (all payers)

Also called: Change Healthcare clearinghouse

Definition: A health care technology and clearinghouse company, part of Optum under UnitedHealth Group, whose systems were disrupted by a cyberattack in February 2024. Listed for reference; not an endorsement or partnership.
Why it matters: Illustrates concentration risk in claim flows.
Illustrative example: A practice reviews its dependence on one clearinghouse.

Verify: confirm current ownership and product names.

Reference source Change Healthcare

Categories EDI & Clearinghouse Terms

Claim Attachment

General (all payers)

Also called: attachments; PWK; 275

Definition: Supporting documents sent with or after a claim, using electronic or paper methods.
Why it matters: Some claims require records to be paid.
Illustrative example: A payer requests notes to support a claim.

Reference source X12

Categories EDI & Clearinghouse TermsClaims Processing

Claim.MD

General (all payers)

Also called: ClaimMD

Definition: A clearinghouse service for submitting claims and checking status. Listed for reference; not an endorsement or partnership.
Why it matters: Used by small practices and billing services.
Illustrative example: A biller uploads claims to Claim.MD.

Related terms Clearinghouse Claim Scrubbing

Reference source Claim.MD

Categories EDI & Clearinghouse Terms

Clearinghouse

General (all payers)

Also called: claims clearinghouse; EDI clearinghouse

Definition: A company that receives claims from providers, checks and reformats them, and routes them to payers, then returns status and remittance data.
Why it matters: Most claims pass through a clearinghouse, which can reject a claim before the payer sees it.
Illustrative example: A practice sends claims via a clearinghouse that forwards them to hundreds of payers.

Reference source X12

Categories EDI & Clearinghouse TermsClaims Processing

Clearinghouse Enrollment

General (all payers)

Also called: payer enrollment through clearinghouse; EDI enrollment

Definition: Registering with a clearinghouse and, for many payers, completing payer-specific EDI setup so claims and remittances flow electronically.
Why it matters: Required before electronic claims for many payers.
Illustrative example: A practice completes EDI enrollment for claims and ERAs.

Related terms Clearinghouse EFT Enrollment

Reference source X12

Categories EDI & Clearinghouse Terms

Clearinghouse Outage Contingency

General (all payers)

Also called: clearinghouse downtime plan; claim submission contingency

Definition: A plan for how a practice will submit claims, check eligibility, and receive payments if its clearinghouse or a major payer connection goes down. The February 2024 Change Healthcare cyberattack disrupted claims and payment flows across the industry.
Why it matters: Practices with a backup route recovered cash flow more easily.
Illustrative example: A practice keeps a second clearinghouse or payer portal access ready.

Verify: see AHA and HHS advisories for the event details.

Reference source American Hospital Association (AHA)

Categories EDI & Clearinghouse TermsRevenue Cycle Metrics

Companion Guide

General (all payers)

Also called: payer companion guide; EDI companion guide

Definition: A payer's document that explains its specific requirements for standard transactions within the HIPAA formats.
Why it matters: Explains payer-specific data requirements that cause rejections.
Illustrative example: A biller reads the companion guide before enrolling.

Reference source X12

Categories EDI & Clearinghouse Terms

Electronic Data Interchange (EDI)

General (all payers)

Also called: EDI; electronic transactions

Definition: The structured electronic exchange of business data, including claims, eligibility, and remittance, between providers, clearinghouses, and payers.
Why it matters: EDI is the backbone of claim submission and payment.
Illustrative example: A practice sends 837P files and receives 835 remittances.

Reference source X12

Categories EDI & Clearinghouse Terms

Experian Health

General (all payers)

Also called: Experian Health clearinghouse

Definition: A health care technology business offering claim management, eligibility, and patient access tools. Listed for reference; not an endorsement or partnership.
Why it matters: Appears in payer and vendor lists.
Illustrative example: A hospital uses Experian Health for eligibility.

Reference source Experian Health

Categories EDI & Clearinghouse Terms

Front-End Edit

General (all payers)

Also called: clearinghouse edit; pre-submission edit

Definition: A check applied before the claim reaches the payer to catch errors.
Why it matters: Reduces payer rejections.
Illustrative example: A front-end edit flags an invalid modifier.

Reference source X12

Categories EDI & Clearinghouse TermsClaims Processing

HIPAA Transaction Standards

General (all payers)

Also called: 5010; HIPAA EDI standards; standard transactions

Definition: The federally adopted formats for electronic health care transactions such as claims, eligibility, and remittance, currently based on X12 version 5010.
Why it matters: Payers must accept standard transactions, and providers who transmit electronically must use them.
Illustrative example: A clearinghouse sends claims in the standard 837 format.

Related terms X12 Companion Guide HIPAA

Reference source X12 · HHS (U.S. Department of Health and Human Services)

Categories EDI & Clearinghouse TermsAudits & Compliance

NCPDP

General (all payers)

Also called: National Council for Prescription Drug Programs

Definition: A standards organization for pharmacy transactions, including e-prescribing standards.
Why it matters: Governs prescription data exchange used by psychiatric prescribers.
Illustrative example: An EHR sends e-prescriptions using NCPDP standards.

Related terms EPCS E-Prescribing (eRx)

Reference source NCPDP

Categories EDI & Clearinghouse TermsEHR & Healthcare Technology Terms

NUBC (National Uniform Billing Committee)

General (all payers)

Also called: NUBC

Definition: The organization that maintains the UB-04 institutional claim form and related code sets.
Why it matters: Defines rules for facility claims.
Illustrative example: A facility follows NUBC guidance for revenue codes.

Related terms UB-04 (CMS-1450)837I

Reference source NUBC

Categories EDI & Clearinghouse Terms

NUCC (National Uniform Claim Committee)

General (all payers)

Also called: NUCC

Definition: The organization that maintains the CMS-1500 claim form and the provider taxonomy code set.
Why it matters: Its instructions define how to fill the CMS-1500.
Illustrative example: A biller follows the NUCC manual for a claim field.

Related terms CMS-1500 Taxonomy Code

Reference source NUCC

Categories EDI & Clearinghouse Terms

Office Ally

General (all payers)

Also called: Office Ally clearinghouse

Definition: A clearinghouse and practice management service used by many small practices. Listed for reference; not an endorsement or partnership.
Why it matters: Frequently used by small behavioral health practices.
Illustrative example: A practice submits claims through Office Ally.

Reference source Office Ally

Categories EDI & Clearinghouse Terms

Payer ID

General (all payers)

Also called: payer identification; EDI payer ID; receiver ID

Definition: The code a clearinghouse uses to route a claim or eligibility request to the correct payer.
Why it matters: Wrong payer IDs cause rejections or misrouted claims.
Illustrative example: A practice uses the payer ID listed on the card or the clearinghouse payer list.

Reference source X12

Categories EDI & Clearinghouse TermsEligibility & Benefits

Payer Portal

General (all payers)

Also called: provider portal; web portal

Definition: A payer's website where providers check eligibility, claims, authorizations, and remittances.
Why it matters: Often the only way to complete certain tasks.
Illustrative example: A biller checks claim status on a payer portal.

Related terms Clearinghouse Claim Status

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories EDI & Clearinghouse TermsEHR & Healthcare Technology Terms

Real-Time Transaction

General (all payers)

Also called: real-time eligibility; real-time claim status

Definition: An electronic request answered immediately, rather than in a batch.
Why it matters: Supports front-desk workflows.
Illustrative example: A front desk checks eligibility in seconds.

Reference source DataSpring (formerly CAQH) · X12

Categories EDI & Clearinghouse Terms

Rejection Report

General (all payers)

Also called: clearinghouse rejection report; error report

Definition: A report from a clearinghouse or payer that lists rejected claims and the reason for each.
Why it matters: Daily review of rejection reports catches problems before timely filing deadlines.
Illustrative example: A biller works the rejection report each morning.

Reference source X12

Categories EDI & Clearinghouse TermsClaims Processing

RelayHealth

General (all payers)

Also called: Relay Health

Definition: A legacy health care technology and clearinghouse brand associated with earlier McKesson and Change Healthcare operations. Listed for reference; not an endorsement or partnership.
Why it matters: Older payer documents may still reference it.
Illustrative example: A payer ID list mentions RelayHealth.

Verify: legacy name; confirm current status.

Related terms Change Healthcare Clearinghouse

Reference source Change Healthcare

Categories EDI & Clearinghouse Terms

SSI Group

General (all payers)

Also called: SSI clearinghouse

Definition: A health care revenue cycle technology company offering clearinghouse and claim tools. Listed for reference; not an endorsement or partnership.
Why it matters: Appears in payer connection lists.
Illustrative example: A payer lists SSI as a supported clearinghouse.

Verify: confirm current brand and offerings.

Related terms Clearinghouse RCM Platform

Reference source SSI Group

Categories EDI & Clearinghouse Terms

Submitter ID

General (all payers)

Also called: submitter identification; EDI submitter ID

Definition: The identifier assigned to the entity sending EDI files to a clearinghouse or payer.
Why it matters: Incorrect IDs cause file rejections.
Illustrative example: A practice enters its submitter ID when setting up a clearinghouse.

Related terms Payer ID Clearinghouse

Reference source X12

Categories EDI & Clearinghouse Terms

T-MSIS

Medicaid (state-specific)

Also called: Transformed Medicaid Statistical Information System; Medicaid data reporting

Definition: T-MSIS, the Transformed Medicaid Statistical Information System, is the system through which states report Medicaid and CHIP data to CMS, including claims and encounter data.
Why it matters: Encounter and claims data from providers and plans feed it, so accurate coding and provider data matter.
Illustrative example: A state Medicaid agency reports encounter data from managed care plans through T-MSIS.

Reference source Medicaid.gov · CMS (Centers for Medicare & Medicaid Services)

Categories EDI & Clearinghouse TermsMedicare & Medicaid Terms Medicaid

TriZetto

General (all payers)

Also called: TriZetto Provider Solutions

Definition: A health care technology company offering clearinghouse and payer and provider software. Listed for reference; not an endorsement or partnership.
Why it matters: Appears in clearinghouse and payer instructions.
Illustrative example: A payer accepts claims from TriZetto.

Verify: confirm current ownership and URL at publish time.

Related terms Clearinghouse Payer ID

Reference source TriZetto Provider Solutions

Categories EDI & Clearinghouse Terms

Vyne Dental

General (all payers)

Also called: Vyne; Vyne Dental clearinghouse

Definition: A clearinghouse and technology company focused on dental claims and attachments. Listed for reference; not an endorsement or partnership.
Why it matters: Primarily dental, so rarely used in behavioral health billing.
Illustrative example: A dental practice submits claims through Vyne.

Verify: confirm current offerings.

Related terms Clearinghouse Claim Attachment

Reference source Vyne Dental

Categories EDI & Clearinghouse Terms

Waystar

General (all payers)

Also called: Waystar clearinghouse; Waystar RCM

Definition: A revenue cycle technology company whose platform includes a claims clearinghouse. It was formed from the merger of Navicure and ZirMed. Listed for reference; not an endorsement or partnership.
Why it matters: Referenced in payer instructions and clearinghouse lists.
Illustrative example: A payer lists Waystar as a supported clearinghouse.

Related terms ZirMed Clearinghouse RCM Platform

Reference source Waystar

Categories EDI & Clearinghouse TermsEHR & Healthcare Technology Terms

WEDI

General (all payers)

Also called: Workgroup for Electronic Data Interchange

Definition: A nonprofit that promotes standards and practices for electronic health information exchange and advises HHS.
Why it matters: Publishes industry guidance on transactions and administrative simplification.
Illustrative example: A practice reads WEDI guidance on EDI.

Related terms HIPAA Transaction Standards X12

Reference source WEDI

Categories EDI & Clearinghouse Terms

X12

General (all payers)

Also called: ASC X12; X12 standards

Definition: The standards development organization whose EDI standards are adopted under HIPAA for health care transactions.
Why it matters: Transaction numbers such as 837 and 835 come from X12.
Illustrative example: A payer's companion guide references X12 version 5010.

Reference source X12

Categories EDI & Clearinghouse Terms

ZirMed

General (all payers)

Also called: ZirMed clearinghouse

Definition: A legacy clearinghouse and revenue cycle company that merged with Navicure to form Waystar. Listed for reference; not an endorsement or partnership.
Why it matters: Older payer lists may still show the ZirMed name.
Illustrative example: A legacy payer ID list mentions ZirMed.

Verify: confirm current status.

Related terms Waystar Clearinghouse

Reference source Waystar

Categories EDI & Clearinghouse Terms