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Billing Terms Glossary
Network Management Billing Terms: Definitions for Therapists and Psychiatrists
In this section
- 12 terms defined
- Written for psychotherapists and psychiatrists
- Source organization linked on every entry
Continuity of Care
General (all payers)Also called: transition of care; transitional care period
- Definition
- A period in which a member can keep seeing a provider who has left the network, at in-network cost sharing, under plan or state rules.
- Why it matters
- It affects how claims from a newly out-of-network clinician are processed for a limited time.
- Illustrative example
- A member in active treatment keeps seeing a therapist during a payer-defined transition period.
Verify: varies by plan and state.
Related terms Network TerminationOut-of-Network (OON)Gap Exception
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Contracting & Network ManagementEligibility & Benefits
Contracted Rate
General (all payers)Also called: negotiated rate; contract rate; in-network rate
- Definition
- The amount a payer has agreed to pay a participating provider for a service under the contract.
- Why it matters
- Sets expected payment and helps spot underpayments.
- Illustrative example
- A payer's contract lists a rate for 90837; the practice compares it to each remittance.
Related terms Fee ScheduleAllowed AmountUnderpaymentParticipation Agreement
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Contracting & Network ManagementPayment & Reimbursement
Fee Schedule
General (all payers)Also called: payer fee schedule; rate schedule; reimbursement schedule
- Definition
- A list of amounts a payer will pay for specific service codes, often tied to a benchmark such as the Medicare fee schedule or set by contract.
- Why it matters
- Provides the basis for expected payment and audit of remittances.
- Illustrative example
- A practice loads its payer's fee schedule into billing software to flag underpayments.
Related terms Medicare Physician Fee Schedule (MPFS)Contracted RateAllowed AmountUnderpayment
Reference source CMS (Centers for Medicare & Medicaid Services) · CMS Physician Fee Schedule
Categories Contracting & Network ManagementPayment & Reimbursement
Gap Exception
General (all payers)Also called: network gap exception; network adequacy exception
- Definition
- A payer's exception allowing a member to use an out-of-network provider at in-network cost sharing because the network lacks an appropriate provider or timely appointment.
- Why it matters
- It is a route to in-network benefits for OON therapists and psychiatrists in areas with thin networks.
- Illustrative example
- A member requests a gap exception because no in-network psychiatrist has an opening.
Verify: rules vary by plan and state.
Related terms Single Case Agreement (SCA)Network AdequacyOut-of-Network (OON)
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Contracting & Network ManagementEligibility & Benefits
In-Network
General (all payers)Also called: in network; network provider
- Definition
- Describes a provider or facility with a contract with the patient's plan, so the patient pays in-network cost sharing.
- Why it matters
- Patients and payers use the term to decide costs; practices must confirm status per plan, not per payer name.
- Illustrative example
- A patient's plan lists a therapist as in-network under its PPO but not under its HMO product.
Related terms Participating Provider (PAR)Out-of-Network (OON)Network Adequacy
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Contracting & Network ManagementEligibility & Benefits
Network Adequacy
General (all payers)Also called: network adequacy standards; access standards
- Definition
- Standards regulators and accreditors set for how many providers of each type, within what distance and time, a health plan must have available.
- Why it matters
- Underlies gap exceptions and regulatory attention on behavioral health access.
- Illustrative example
- A regulator reviews whether a plan has enough in-network therapists in a county.
Related terms Gap ExceptionGhost NetworkProvider Directory
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Contracting & Network Management
Network Termination
General (all payers)Also called: provider termination; contract termination
- Definition
- The end of a provider's participation in a payer's network, initiated by either side under contract terms.
- Why it matters
- Termination changes reimbursement and can require patient notice and continuity-of-care handling.
- Illustrative example
- A payer terminates a therapist for failure to recredential.
Related terms RecredentialingContinuity of CareParticipation Agreement
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Contracting & Network ManagementCredentialing & Enrollment
Non-Participating Provider (Non-PAR)
General (all payers)Also called: non-par; out-of-network provider; OON provider
- Definition
- A provider who has no contract with a payer. Claims are paid, if the plan has out-of-network benefits, under different rules and reimbursement.
- Why it matters
- Determines whether the patient can be billed the difference between charge and allowed amount.
- Illustrative example
- A therapist without a contract gives the patient a superbill to submit for out-of-network reimbursement.
Related terms Participating Provider (PAR)Out-of-Network (OON)SuperbillBalance Billing
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Contracting & Network Management
Out-of-Network (OON)
General (all payers)Also called: OON; out of network benefits; non-network
- Definition
- Describes care from a provider with no contract with the patient's plan. Coverage depends on whether the plan has out-of-network benefits.
- Why it matters
- OON claims can pay less and carry higher patient cost sharing, and HMO plans may not pay at all.
- Illustrative example
- A PPO reimburses 60% of the allowed amount for OON therapy after the OON deductible.
Verify: plan-specific.
Related terms Non-Participating Provider (Non-PAR)Balance BillingSingle Case Agreement (SCA)
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Contracting & Network ManagementEligibility & Benefits
Participating Provider (PAR)
General (all payers)Also called: PAR provider; in-network provider; contracted provider
- Definition
- A provider who has signed a contract with a payer and agrees to accept its allowed amounts as payment in full for covered services, apart from member cost sharing.
- Why it matters
- In-network status controls what the practice is paid and what it can bill the patient.
- Illustrative example
- A therapist with a PAR contract accepts the payer's allowed amount and collects only the patient's copay.
Related terms Non-Participating Provider (Non-PAR)Allowed AmountBalance BillingContracted Rate
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Contracting & Network ManagementCredentialing & Enrollment
Participation Agreement
General (all payers)Also called: provider agreement; provider contract; network contract
- Definition
- The contract between a provider and a payer that sets reimbursement, billing rules, timely filing, appeals, and termination terms.
- Why it matters
- Contract terms override general rules, so the agreement is the first place to check for payer-specific requirements.
- Illustrative example
- A practice checks its contract for the timely filing limit before disputing a denial.
Related terms Contracted RateTimely FilingFee ScheduleNetwork Termination
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Contracting & Network Management
Single Case Agreement (SCA)
General (all payers)Also called: SCA; letter of agreement; LOA; single case rate
- Definition
- A one-time agreement between a payer and an out-of-network provider to cover a specific member's care at an agreed rate.
- Why it matters
- It can let a member see a needed provider at in-network cost sharing when no adequate in-network option exists.
- Illustrative example
- A payer approves an SCA for 12 sessions at a negotiated rate.
Verify: availability and process are payer-specific.
Related terms Gap ExceptionOut-of-Network (OON)Network AdequacyContinuity of Care
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Contracting & Network ManagementEligibility & Benefits
More billing terms
- Credentialing & Enrollment 58
- 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
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