Medical Billing Terms N-O: OIG Compliance, NUCC and Out-of-Network Terms

OIG compliance means following the guidance of the HHS Office of Inspector General to prevent fraud, waste and abuse in billing. This page defines it with the terms from NPSG.15.01.01 to overpayment, including NUCC, the OIG work plan, out-of-network and overpayment. Each entry gives a plain definition, why it matters, an example, and an official source. MCM South Medical Billing Service, LLC works only in mental and behavioral health billing.

Last reviewed: October 10, 2026Sources linked at each term

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Billing Terms Glossary slide, Terms N-O: OIG Compliance - MCM South Medical Billing Service, LLC

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On this page (24 terms)

NPSG.15.01.01 Suicide Risk Reduction
NQF (National Quality Forum)
NUBC (National Uniform Billing Committee)
NUCC 1500 Claim Form Instruction Manual
NUCC (National Uniform Claim Committee)
NY Medicaid Managed Care
OCR (Office for Civil Rights)
Office Ally
Offset
OIG General Compliance Program Guidance
OIG (Office of Inspector General)
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

How to use these OIG Compliance definitions

Use this page as a quick reference for OIG Compliance, from NPSG.15.01.01 Suicide Risk Reduction to Overpayment. Each entry gives a plain definition, why it matters to a mental health practice, and an official source. When a rule changes by payer or state, the entry says so, so confirm OIG Compliance details with the payer before you bill.

Checklist: put the oig compliance definitions to work

Check the oig compliance entries above before you send a claim that depends on them.
Share this oig compliance page with front-desk and billing staff so everyone works from the same definitions.
When a payer letter mentions oig compliance, find the matching entry and note the date you checked it.
Keep your oig compliance notes next to your payer contracts, because a contract can define a term differently.
Ask the payer to confirm in writing how it applies oig compliance before you change a workflow.
Train new staff on oig compliance first, then move on to the rest of the glossary.
Log any oig compliance question that comes up twice, then add the answer to your billing procedures.
Use the source links under the oig compliance entries to confirm the current rule.
Print the oig compliance entries you use most and keep them at the billing desk.

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NPSG.15.01.01 Suicide Risk Reduction

General (all payers)

Also called NPSG 15.01.01; Joint Commission suicide prevention goal; suicide risk assessment requirement

Definition: NPSG.15.01.01 is a Joint Commission goal on reducing suicide risk. A Joint Commission FAQ dated February 1, 2022 says it applies to all patients in organizations surveyed under the Behavioral Health Care and Human Services standards, along with other settings for patients being evaluated or treated for a behavioral condition as the main reason for care and patients who express suicidal ideation.
Why it matters: Accredited behavioral health organizations use it to shape screening, assessment, and safety planning. Payers do not usually bill for it, but accreditors and surveyors look for it.
Illustrative example: An accredited clinic screens each patient for suicide risk and documents the assessment and the safety plan.

Reference sourceThe Joint Commission The Joint Commission, NPSG suicide risk FAQ (2/1/2022)checked 10/9/26

CategoriesQuality & Risk Adjustment Terms Behavioral Health Specific Terms

NQF (National Quality Forum)

General (all payers)

Also called NQF

Definition: A nonprofit that historically endorsed health care quality measures used in federal programs.
Why it matters: Measure endorsement history appears in quality documentation.
Illustrative example: A quality measure notes its NQF endorsement number.

Reference sourceNational Quality Forum (NQF)checked 10/9/26

CategoriesQuality & Risk Adjustment 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 termsUB-04 (CMS-1450)837I

Reference sourceNUBCchecked 10/9/26

CategoriesEDI & Clearinghouse Terms

NUCC 1500 Claim Form Instruction Manual

General (all payers)

Also called 1500 instruction manual; CMS-1500 instructions; NUCC manual; claim form manual

Definition: The NUCC 1500 Claim Form Reference Instruction Manual is the National Uniform Claim Committee's guide to completing the 1500 Health Insurance Claim Form. NUCC states that its purpose is to help standardize nationally how the form is completed. The version on the NUCC site when checked was Version 13.0, dated July 2025.
Why it matters: Payers may add their own rules, but the manual is the starting point for what each box means. Use it to settle disputes about how to fill a box, and check the payer's own instructions for special cases.
Illustrative example: A biller checks the NUCC manual to see what Box 22 needs for a replacement claim before resubmitting.

Reference sourceNUCC, 1500 Claim Form Reference Instruction Manual, Version 13.0 (7/25)NUCCchecked 10/9/26

CategoriesClaims Processing

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 termsCMS-1500 Taxonomy Code

Reference sourceNUCCchecked 10/9/26

CategoriesEDI & Clearinghouse Terms

NY Medicaid Managed Care

Medicaid (state-specific)

Also called MAP; HARP; New York Medicaid plans

Definition: New York's Medicaid managed care landscape, including specialty arrangements such as Health and Recovery Plans (HARPs) for people with behavioral health needs.
Why it matters: New York is a served state; MAP transitions are a known moving target.
Illustrative example: A New York provider checks whether a member is in a specialty plan before billing.

Reference sourceMedicaid.govchecked 10/9/26

CategoriesMedicare & Medicaid Terms BCBS, UHC & Commercial Payer Terms

OCR (Office for Civil Rights)

General (all payers)

Also called OCR; HHS OCR

Definition: The HHS office that enforces HIPAA privacy, security, and breach rules and civil rights laws in health programs.
Why it matters: OCR investigates HIPAA complaints and publishes enforcement guidance.
Illustrative example: A patient files a HIPAA complaint with OCR.

Related termsHIPAA HIPAA Privacy Rule

Reference sourceHHS Office for Civil Rights (OCR)checked 10/9/26

CategoriesAudits & Compliance

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 sourceOffice Allychecked 10/9/26

CategoriesEDI & Clearinghouse Terms

Offset

General (all payers)

Also called payment offset; claim offset

Definition: A payer's method of recovering an overpayment by subtracting it from a future payment.
Why it matters: Offsets appear on ERAs and confuse posting if not tracked.
Illustrative example: An ERA shows a negative line item for prior overpayment.

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesPayment & Reimbursement

OIG General Compliance Program Guidance

General (all payers)

Also called OIG compliance program guidance; GCPG; OIG seven elements

Definition: OIG General Compliance Program Guidance is a voluntary guidance document from the HHS Office of Inspector General that describes how health care organizations can design a compliance program.
Why it matters: Practices use it to build a compliance program that fits their size. It covers elements such as policies, training, monitoring, and response to problems.
Illustrative example: A small group uses the OIG guidance to write its compliance policies and training plan.

Reference sourceHHS Office of Inspector General (OIG)checked 10/9/26

CategoriesAudits & Compliance

OIG (Office of Inspector General)

General (all payers)

Also called OIG; HHS OIG

Definition: The HHS office that investigates fraud, waste, and abuse in health programs and publishes exclusion lists and compliance guidance.
Why it matters: OIG guidance shapes compliance programs and its exclusion list must be checked.
Illustrative example: A practice screens staff against the OIG exclusion list monthly.

Reference sourceHHS Office of Inspector General (OIG)checked 10/9/26

CategoriesAudits & Compliance

OIG Self-Disclosure Protocol

General (all payers)

Also called SDP; OIG self disclosure; voluntary self-disclosure

Definition: The OIG Self-Disclosure Protocol is a process that lets a provider voluntarily disclose potential violations of federal health care fraud laws to OIG and seek resolution.
Why it matters: It is for potential fraud, not simple overpayments that can go through normal refund channels. Use it only after counsel reviews the facts.
Illustrative example: A practice finds a possible kickback issue, and its attorney evaluates whether to use the protocol.

Reference sourceHHS Office of Inspector General (OIG)checked 10/9/26

CategoriesAudits & Compliance

OIG Work Plan

General (all payers)

Also called OIG audit priorities; HHS OIG work plan

Definition: The OIG Work Plan is a list of audits and evaluations that the HHS Office of Inspector General plans or has under way. OIG updates it on a regular basis.
Why it matters: It shows what regulators are looking at, such as behavioral health billing or telehealth. Compliance teams review it to guide internal audits.
Illustrative example: A compliance officer checks the work plan and schedules an internal review of the practice's high-level psychotherapy claims.

Reference sourceHHS Office of Inspector General (OIG)checked 10/9/26

CategoriesAudits & Compliance

Open Panel

General (all payers)

Also called closed panel; panel status

Definition: A payer's status for a specialty or area: open panels accept new applicants, closed panels do not, often because the payer considers the network full.
Why it matters: A closed-panel rejection is a common reason new therapists cannot join a network.
Illustrative example: A payer tells a solo therapist its panel for that county is closed.

Reference sourceNCQAchecked 10/9/26

CategoriesCredentialing & Enrollment Contracting & Network Management

Opioid Treatment Program (OTP)

General (all payers)

Also called OTP; methadone clinic

Definition: A federally regulated program that provides medications for opioid use disorder, such as methadone, along with counseling.
Why it matters: Medicare and Medicaid have bundled payment rules for OTPs.
Illustrative example: An OTP bills weekly bundled payments where allowed.

Reference sourceSAMHSA CMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesBehavioral Health Specific Terms Medicare & Medicaid Terms

Opt-Out (Medicare)

General (all payers)

Also called Medicare opt-out; private contract with Medicare patient

Definition: A formal choice by certain practitioners to stop billing Medicare and instead contract privately with beneficiaries under specific rules.
Why it matters: Opting out has strict paperwork and duration rules; mistakes can jeopardize Medicare payment.
Illustrative example: A psychiatrist files an opt-out affidavit and then uses private contracts with Medicare patients.

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesCredentialing & Enrollment Medicare & Medicaid Terms

Optum

Private payer

Also called Optum Behavioral Health; OptumHealth

Definition: The health services business of UnitedHealth Group. Optum entities manage behavioral health benefits for many UnitedHealthcare plans and offer other services.
Why it matters: A therapist may be credentialed with Optum for UnitedHealthcare behavioral health.
Illustrative example: A claim goes to the payer ID listed for behavioral health on the card.

Reference sourceOptumchecked 10/9/26

CategoriesBCBS, UHC & Commercial Payer Terms

Optum Pay

General (all payers)

Also called Optum payments

Definition: A payment and remittance service from Optum used by some payers to deliver provider payments. Listed for reference; not an endorsement or partnership.
Why it matters: Payment method rules and fees vary.
Illustrative example: A provider enrolls in Optum Pay to receive payments.

Reference sourceOptum Paychecked 10/9/26

CategoriesPayment & Reimbursement

Oracle Health

General (all payers)

Also called Cerner; Oracle Cerner

Definition: Oracle's health information technology business, formerly Cerner, offering EHR and related systems mainly to health systems. Listed for reference; not an endorsement or partnership.
Why it matters: Legacy name Cerner still appears in payer and provider workflows.
Illustrative example: A health system uses Oracle Health for its EHR.

Related termsEHR (Electronic Health Record)

Reference sourceOracle Healthchecked 10/9/26

CategoriesEHR & Healthcare Technology Terms

Originating Site

General (all payers)

Also called patient site; telehealth originating site

Definition: Under Medicare telehealth rules, the location where the patient receives the service, historically subject to geographic and site restrictions with exceptions for mental health.
Why it matters: Site rules affect eligibility for Medicare payment.
Illustrative example: A patient's home is an allowed site for some Medicare mental health telehealth.

Related termsDistant Site Telehealth

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesTelehealth Terms Medicare & Medicaid Terms

Oscar Health

Private payer

Also called Oscar

Definition: A health insurer focused on individual and small group marketplace plans.
Why it matters: Has its own network and rules.
Illustrative example: A provider checks Oscar's portal.

Reference sourceOscar Healthchecked 10/9/26

CategoriesBCBS, UHC & Commercial Payer Terms

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.

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesContracting & Network Management Eligibility & Benefits

Out-of-Pocket Maximum

General (all payers)

Also called OOP max; out-of-pocket limit

Definition: The most a member pays in a plan year for covered in-network services; after it is reached, the plan pays 100% of covered in-network costs.
Why it matters: Determines when patient responsibility stops for the year.
Illustrative example: A member meets the OOP max and the plan pays all remaining covered claims.

Related termsDeductible Coinsurance Copay

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesPatient Financial Responsibility Terms Eligibility & Benefits

Overpayment

General (all payers)

Also called overpaid claim; refund due

Definition: A payment greater than the amount the provider was entitled to, which typically must be returned within timelines set by law or contract.
Why it matters: Keeping known overpayments can create compliance exposure, including under the False Claims Act for Medicare and Medicaid.
Illustrative example: A duplicate payment is identified and refunded.

Reference sourceCMS (Centers for Medicare & Medicaid Services)HHS Office of Inspector General (OIG)checked 10/9/26

CategoriesPayment & Reimbursement Audits & Compliance

Quick answer: OIG Compliance

What does the OIG do?

The HHS office that investigates fraud, waste, and abuse in health programs and publishes exclusion lists and compliance guidance. OIG guidance shapes compliance programs and its exclusion list must be checked.

Frequently asked questions: OIG Compliance

What is the NUCC?

NUCC (National Uniform Claim Committee) is the organization that maintains the CMS-1500 claim form and the provider taxonomy code set. Its instructions define how to fill the CMS-1500.

What does out-of-network mean?

Describes care from a provider with no contract with the patient's plan. Coverage depends on whether the plan has out-of-network benefits. OON claims can pay less and carry higher patient cost sharing, and HMO plans may not pay at all.

What is an overpayment in medical billing?

Overpayment is a payment greater than the amount the provider was entitled to, which typically must be returned within timelines set by law or contract. Keeping known overpayments can create compliance exposure, including under the False Claims Act for Medicare and Medicaid.

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Where MCM South works

MCM South serves psychotherapists and psychiatrists in ten states: Georgia, Massachusetts, Connecticut, Texas, Florida, New York, Colorado, Tennessee, North Carolina and Illinois.

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