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2. National Uniform Billing Committee - Wikipedia

   en.wikipedia.org/wiki/National_Uniform_Billing...

   The National Uniform Billing Committee (NUBC) is the governing body for forms and codes use in medical claims billing in the United States for institutional providers like hospitals, nursing homes, hospice, home health agencies, and other providers. The NUBC was formed by the American Hospital Association (AHA) in 1975. [3]

3. Medical billing - Wikipedia

   en.wikipedia.org/wiki/Medical_billing

   A medical biller then takes the coded information, combined with the patient's insurance details, and forms a claim that is submitted to the payors. [2] Payors evaluate claims by verifying the patient's insurance details, medical necessity of the recommended medical management plan, and adherence to insurance policy guidelines. [4]

4. Utilization management - Wikipedia

   en.wikipedia.org/wiki/Utilization_management

   Utilization management is "a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision," as defined by the Institute of Medicine [1] Committee on Utilization Management by Third Parties (1989; IOM is now the National ...

5. Consolidated Clinical Document Architecture - Wikipedia

   en.wikipedia.org/wiki/Consolidated_Clinical...

   Continuity of Care Document - The Continuity of Care Document (CCD) represents a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. The primary use case for the CCD is to provide a snapshot in time containing the germane ...

6. Health insurance in the United States - Wikipedia

   en.wikipedia.org/wiki/Health_insurance_in_the...

   Recent claim experience—whether better or worse than average—is a strong predictor of future costs in the near term. But the average health status of a particular small employer group tends to regress over time towards that of an average group. [91] The process used to price small group coverage changes when a state enacts small group ...

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8. Revenue cycle management - Wikipedia

   en.wikipedia.org/wiki/Revenue_cycle_management

   The claim is then sent out from the provider to the payer in an ANSI 837 5010 standard format. Denials can be sent back as a response to the claim from the payer stating a specific reason of why the claim cannot be adjudicated. This is where denial management processes help to ensure that there is an immediate resolution to these denials.

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