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Billing Terms Glossary
Provider Data Terms: Definitions for Therapists and Psychiatrists
In this section
- 17 terms defined
- Written for psychotherapists and psychiatrists
- Source organization linked on every entry
Billing Provider
General (all payers)Also called: billing entity; pay-to provider
- Definition
- The provider or organization that submits the claim and is paid. It can differ from the rendering provider who delivered the service.
- Why it matters
- Errors here send payments to the wrong entity or trigger rejections.
- Illustrative example
- A group is the billing provider; a therapist in the group is the rendering provider.
Related terms Rendering ProviderType 2 NPIReferring Provider
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Provider Data Management TermsClaims Processing
CAQH ProView Data Sharing
General (all payers)Also called: ProView data sharing
- Definition
- The way CAQH ProView shares a provider's profile data with authorized payers and organizations.
- Why it matters
- Sets what payers can see.
- Illustrative example
- A provider reviews which payers can view the profile.
Related terms CAQH ProViewAuthorization to Access CAQH
Reference source CAQH
Categories Provider Data Management TermsEHR & Healthcare Technology Terms
Ghost Network
General (all payers)Also called: phantom network; inaccurate network
- Definition
- A network whose directory lists providers who are not actually available, accepting new patients, or in network.
- Why it matters
- Ghost networks are a known access problem in behavioral health and a regulatory focus.
- Illustrative example
- A member calls ten listed therapists and none accepts new patients.
Related terms Provider DirectoryNetwork AdequacyProvider Data Accuracy
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Provider Data Management TermsContracting & Network Management
Group NPI
General (all payers)Also called: billing NPI; organizational billing NPI
- Definition
- The Type 2 NPI a group uses as its billing provider identifier.
- Why it matters
- It must match the group's tax ID and payer enrollment or claims will not pay to the right entity.
- Illustrative example
- A group enrolls with a payer under its group NPI and tax ID.
Related terms Type 2 NPITax Identification Number (TIN)Group Enrollment
Reference source CMS (Centers for Medicare & Medicaid Services) · NPPES (NPI Registry)
Categories Provider Data Management TermsCredentialing & Enrollment
Medicaid ID
General (all payers)Also called: Medicaid provider ID; Medicaid billing number
- Definition
- The identifier a state Medicaid program assigns to an enrolled provider for billing.
- Why it matters
- Claims to Medicaid or its plans need the correct provider ID or NPI as the state requires.
- Illustrative example
- A state requires a Medicaid ID on claims in addition to the NPI.
Verify: state-specific.
Related terms State Medicaid EnrollmentNPI (National Provider Identifier)
Reference source Medicaid.gov
Categories Provider Data Management TermsMedicare & Medicaid Terms
NPI (National Provider Identifier)
General (all payers)Also called: NPI number; National Provider Identifier
- Definition
- A unique 10-digit identification number assigned to health care providers under HIPAA and used on all standard transactions.
- Why it matters
- Every claim must carry the correct NPI; the wrong one causes rejections.
- Illustrative example
- A therapist uses their individual NPI on claims; a group uses a separate group NPI.
Related terms Type 1 NPIType 2 NPINPPESTaxonomy Code
Reference source CMS (Centers for Medicare & Medicaid Services) · NPPES (NPI Registry)
Categories Provider Data Management TermsCredentialing & Enrollment
NPPES
General (all payers)Also called: National Plan and Provider Enumeration System; NPI registry
- Definition
- The CMS system where providers apply for an NPI and keep their NPI record up to date.
- Why it matters
- Outdated NPPES data (address, taxonomy) can cause claim edits and directory errors.
- Illustrative example
- A practice moves offices and updates its address in NPPES.
Related terms NPI (National Provider Identifier)Taxonomy CodeProvider Data Accuracy
Reference source CMS (Centers for Medicare & Medicaid Services) · NPPES (NPI Registry)
Categories Provider Data Management Terms
Provider Data Accuracy
General (all payers)Also called: provider directory accuracy; provider demographics
- Definition
- The correctness of a provider's address, phone, specialty, licenses, and network status across payer and public directories.
- Why it matters
- Federal and state rules and accreditors push payers to keep directories accurate, and errors can delay credentialing or payment.
- Illustrative example
- A payer directory shows an old address, so members call the wrong location.
Related terms Provider DirectoryCAQH ProViewGhost Network
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Provider Data Management TermsContracting & Network Management
Provider Directory
General (all payers)Also called: network directory; find-a-provider listing
- Definition
- A payer's public list of in-network providers with contact and specialty information.
- Why it matters
- Inaccurate listings frustrate members and can trigger compliance scrutiny for the payer.
- Illustrative example
- A member cannot find a therapist listed in the directory who is no longer taking new patients.
Related terms Provider Data AccuracyGhost NetworkNetwork Adequacy
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Provider Data Management TermsContracting & Network Management
Provider Taxonomy Mismatch
General (all payers)Also called: taxonomy mismatch
- Definition
- A claim edit that fires when the taxonomy on the claim does not match what the payer holds for that provider.
- Why it matters
- A common, avoidable cause of rejections for new clinicians.
- Illustrative example
- A claim is rejected because the claim lists one taxonomy and the payer file has another.
Related terms Taxonomy CodeClaim RejectionProvider Data Accuracy
Reference source NUCC
Categories Provider Data Management TermsDenials & Appeals
Referring Provider
General (all payers)Also called: referring physician; ordering provider
- Definition
- The clinician who refers a patient to another provider, sometimes required on the claim.
- Why it matters
- Some payers, plans, and programs require the referring provider's NPI to pay the claim.
- Illustrative example
- A Medicaid plan requires the PCP's NPI as referring provider.
Verify: payer-specific.
Related terms Billing ProviderRendering ProviderReferral
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Provider Data Management TermsClaims Processing
Rendering Provider
General (all payers)Also called: treating provider; performing provider
- Definition
- The individual clinician who actually delivered the service being billed.
- Why it matters
- Payers credential and pay based on the rendering provider's status.
- Illustrative example
- A supervised associate may not be an allowed rendering provider under some payer policies.
Related terms Billing ProviderType 1 NPISupervising Provider
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Provider Data Management TermsClaims Processing
Roster Validation
General (all payers)Also called: directory validation; data attestation request
- Definition
- A payer's periodic request that providers confirm or correct their directory data.
- Why it matters
- Ignoring it can lead to directory removal or payment issues.
- Illustrative example
- A payer emails a link to confirm addresses; the practice confirms in the portal.
Related terms Provider Data AccuracyAttestation
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Provider Data Management Terms
Tax Identification Number (TIN)
General (all payers)Also called: TIN; EIN; tax ID
- Definition
- The number the IRS assigns to a billing entity; payers use it to issue payment and 1099 forms. It appears on claims as the billing provider's tax ID.
- Why it matters
- A TIN mismatch between the claim, the contract, and the payer enrollment can hold or misdirect payment.
- Illustrative example
- A practice changes its legal entity and must update its TIN with every payer.
Related terms Group NPIBilling ProviderPayment Address
Reference source CMS (Centers for Medicare & Medicaid Services)
Categories Provider Data Management TermsPayment & Reimbursement
Taxonomy Code
General (all payers)Also called: provider taxonomy; healthcare provider taxonomy code; NUCC taxonomy
- Definition
- A 10-character code from the NUCC Health Care Provider Taxonomy code set that describes a provider's type and specialty.
- Why it matters
- Some payers edit claims against the taxonomy on file; a mismatch can reject or deny claims.
- Illustrative example
- A psychologist's NPPES record lists a psychologist taxonomy that matches what the payer has on file.
Verify: confirm the exact code on the current NUCC taxonomy list.
Related terms NPI (National Provider Identifier)NUCC (National Uniform Claim Committee)NPPESProvider Taxonomy Mismatch
Reference source NUCC
Categories Provider Data Management TermsEDI & Clearinghouse Terms
Type 1 NPI
General (all payers)Also called: individual NPI; individual provider NPI
- Definition
- The NPI assigned to an individual health care provider, such as a psychologist, therapist, or psychiatrist. A person can have only one.
- Why it matters
- It identifies the treating or rendering clinician on claims.
- Illustrative example
- A solo therapist bills under a Type 1 NPI as both rendering and billing provider.
Related terms NPI (National Provider Identifier)Type 2 NPIRendering Provider
Reference source CMS (Centers for Medicare & Medicaid Services) · NPPES (NPI Registry)
Categories Provider Data Management Terms
Type 2 NPI
General (all payers)Also called: organizational NPI; group NPI
- Definition
- The NPI assigned to an organization, such as a group practice or clinic, that bills for services.
- Why it matters
- Group claims list the Type 2 NPI as the billing provider, while the individual's Type 1 NPI is the rendering provider.
- Illustrative example
- A group therapy practice bills under its Type 2 NPI with each therapist's Type 1 NPI as rendering.
Related terms Type 1 NPIBilling ProviderRendering ProviderGroup NPI
Reference source CMS (Centers for Medicare & Medicaid Services) · NPPES (NPI Registry)
Categories Provider Data Management Terms
More billing terms
- 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
- Patient Financial Responsibility Terms 35
- AI & Healthcare Automation Terms 12
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