> ## Documentation Index
> Fetch the complete documentation index at: https://www.practiceownersguide.com/llms.txt
> Use this file to discover all available pages before exploring further.

# Glossary

> Terms as used across this guide, organized by domain, with links to the pages that treat them fully. Alphabetical within each section.

Terms as used across this guide, organized by domain, with links to the pages that treat them fully. Alphabetical within each section.

## Claims, remittances, and the money pipeline

**835 / ERA:** The X12 835 Health Care Claim Payment/Advice; the electronic remittance advice explaining a payer's payment, claim by claim. The HIPAA-standard remittance format. → [What is an 835?](/concepts/what-is-an-835)

**837:** The X12 claim transaction (837P professional, 837D dental, 837I institutional); how claims travel to payers. → [Claim lifecycle](/concepts/claim-lifecycle)

**270/271, 276/277:** X12 eligibility inquiry/response and claim status inquiry/response transactions.

**Adjudication:** The payer's process of deciding what to pay on a claim: pay, reduce, deny, or pend.

**Allowed amount:** The contracted price for a service under your participation agreement; the ceiling from which payment and patient responsibility are carved.

**BPR / BPR10:** The 835's payment-header segment; BPR10 carries the payer's originating company ID, used in [reassociation](/concepts/eft-reassociation).

**CARC / RARC:** Claim Adjustment Reason Codes and Remittance Advice Remark Codes; the standardized vocabulary of adjustments and denials ([x12.org/codes](https://x12.org/codes)). → [Reading denial codes](/concepts/carc-rarc-denial-codes)

**CAS segment:** Where adjustments live in an 835; group code + CARC + amount, required to balance against billed charges.

**Clean claim:** A claim that adjudicates without rejection, denial, or requests for more information; **clean claim rate** measures your front-end quality.

**Clearinghouse:** The switch between your PM system and payers: claim validation ("scrubbing"), routing, and often ERA delivery.

**Coordination of benefits (COB):** Determining payment order when a patient has multiple coverages; a top denial source (CO-109, CO-22).

**CPT / HCPCS / CDT / ICD-10:** The code sets: procedures (CPT/HCPCS medical, CDT dental) and diagnoses (ICD-10) that claims are written in.

**EOB:** Explanation of benefits; the human-readable remittance, typically paper or PDF. → [ERA vs. EOB](/concepts/era-vs-eob)

**Fee schedule:** Your contracted rates with a payer, per code. Know your top 20; audit that you're actually paid them.

**PLB segment:** Provider-level adjustments in an 835 (recoupments, interest, withholds); the usual explanation for deposit-vs-remittance shortfalls.

**Posting:** Applying a remittance's payments and adjustments to open claims in the PM system.

**Prior authorization:** Payer pre-approval required before certain services; skipping it produces CO-197 denials with weak appeal rights.

**Reassociation:** Matching an EFT deposit to its 835 via trace number (TRN) and originating company ID. → [EFT reassociation](/concepts/eft-reassociation)

**Reconciliation (remittance-to-deposit):** Tying every remittance to a bank deposit and every payer deposit to a remittance; the control that catches missing money. → [Reconciliation](/concepts/reconciliation)

**Recoupment:** A payer clawing back a prior overpayment, usually by offsetting future remittances (see PLB).

**Superbill:** An itemized encounter form (codes + charges) a cash-pay or out-of-network patient submits to their own insurer for reimbursement.

**Timely filing:** The contractual deadline for claim submission; missed = denied (CO-29) with narrow appeal rights.

**TRN segment:** The 835's trace number; the reassociation key that also rides the ACH addenda.

## Enrollment, credentialing, and identity

**Aggregator (payment):** A vendor operating payments/remittances for many payers (Zelis, ECHO, Optum Pay, Payspan). Enrollment and payment-method elections often live with the aggregator, not the payer. → [Enrollment directory](/reference/payer-enrollment-directory)

**CAQH ProView:** The industry-standard credentialing data repository most commercial payers pull from; requires quarterly re-attestation. → [Get credentialed](/guides/get-credentialed)

**CMS-588:** Medicare's EFT authorization form, filed via PECOS.

**Credentialing / contracting / enrollment:** Three distinct steps payers require: verifying you, agreeing rates with you, configuring their systems to pay you. → [Get credentialed](/guides/get-credentialed)

**EFT:** Electronic funds transfer; payer payment by ACH. HIPAA-covered payers must offer it on request (45 C.F.R. § 162.1602). → [Enroll in EFT/ERA](/guides/enroll-eft-era)

**EIN / TIN:** The entity's federal tax identifiers; the identity payer contracts and enrollments attach to.

**I\&A account:** CMS Identity & Access login managing NPPES and PECOS access.

**NPI (Type 1 / Type 2):** National Provider Identifier for individuals (Type 1) and organizations (Type 2), via [NPPES](https://nppes.cms.hhs.gov/).

**PECOS:** Medicare's provider enrollment system.

**Virtual credit card (VCC):** Payer payment via one-time card number, costing the practice interchange fees; declinable in favor of EFT. → [ERA vs. EOB](/concepts/era-vs-eob)

## Patient payments and financing

**BNPL (buy now, pay later):** General point-of-sale installment products (e.g., Affirm) occasionally used in healthcare; distinct from healthcare-specialized financing.

**Card-on-file:** Stored patient payment credentials with authorization to charge balances; the backbone of pre-service collection and self-carried payment plans.

**Deferred interest:** Promotional financing structure (classically CareCredit-style) where interest accrues retroactively if the balance isn't cleared within the promo period; a patient-experience and regulatory-scrutiny hotspot, disclose carefully.

**Good Faith Estimate (GFE):** The written cost estimate the No Surprises Act requires for uninsured/self-pay patients for scheduled services (45 C.F.R. § 149.610). Applies to cash-pay practices broadly. → [Owner's task repo](/reference/owners-task-repo)

**Merchant discount fee:** What the practice pays a financing provider or card processor per transaction; in patient financing it varies by plan length and promo type, the number to compare across Cherry/CareCredit/Sunbit-type products.

**Patient financing (third-party):** Point-of-sale installment products (Cherry, Sunbit, CareCredit et al.): the practice is paid upfront minus a fee; the patient repays the financer. → [Owner's task repo, Part 3](/reference/owners-task-repo)

**Patient responsibility:** Deductible, coinsurance, copay, the PR-group-coded share of the allowed amount collected from the person, not the payer.

**Surcharging:** Passing card fees to patients; regulated by state law and often restricted by payer contracts for insured balances.

## Practice models

**Cash-pay / direct-pay practice:** No payer contracts; patients pay directly (often with superbills for out-of-network reimbursement). Removes credentialing; adds GFE duties and a Medicare-posture decision. → [Owner's task repo, Part 2B](/reference/owners-task-repo)

**Concierge medicine:** Membership fee for access/amenities, typically *on top of* insurance billing, which is what distinguishes it from DPC and creates the duplicate-billing questions DPC avoids.

**Direct primary care (DPC):** Flat periodic membership covering defined primary-care services, no insurance billing; exempted from insurance regulation by statute in many states when structured to fit.

**Hybrid model:** Insurance base plus cash service lines and/or telehealth; watch the seams (copay waivers, GFE consistency, revenue-stream segregation). → [Owner's task repo, Part 2D](/reference/owners-task-repo)

**Medicare opt-out:** The formal process (affidavit + private contracts, 42 U.S.C. § 1395a(b)) required to treat Medicare beneficiaries on a private cash basis; renews automatically in two-year cycles.

## Telehealth

**Compacts (IMLC / PSYPACT / NLC):** Interstate licensure vehicles (physicians / psychologists / nurses) that expand a telehealth practice's map without full per-state licensure.

**Distant site / originating site:** Where the clinician is / where the patient is, in Medicare telehealth rules; the patient's location governs licensure generally.

**EPCS:** Electronic prescribing of controlled substances; certified e-prescribing required alongside DEA registration.

**Payment parity:** State rules on whether payers must reimburse telehealth at in-person rates; varies by state and modality.

**Ryan Haight Act:** Federal law requiring an in-person evaluation before controlled-substance prescribing via telemedicine, subject to DEA flexibilities that have been extended repeatedly (currently through 2026). → [Owner's task repo, Part 2C](/reference/owners-task-repo)

## Compliance and regulatory

**AKS (Anti-Kickback Statute):** Federal prohibition on remuneration for referrals of federal-program business (42 U.S.C. § 1320a-7b); the reason routine copay waivers and referral arrangements need counsel.

**BAA (Business Associate Agreement):** The HIPAA-required contract with every vendor touching PHI, EHR, email, texting, billing service, financing platform. Inventory annually.

**CLIA waiver:** Certification required for even simple in-office lab tests (CLIA, 42 U.S.C. § 263a); renewable.

**CPOM:** Corporate practice of medicine doctrine; state-law restrictions on who may own clinical practice entities. → [CPOM and the PC](/concepts/cpom-and-the-pc) and the [MSO-PC Wiki](https://mso.getlemma.com)

**Escheatment:** State unclaimed-property law; where stale patient credits legally go if unrefunded. → [Patient refunds](/guides/send-patient-refunds)

**HIPAA security risk analysis:** The annual, documented security assessment 45 C.F.R. § 164.308 requires; the first thing OCR asks for after a breach.

**No Surprises Act:** Federal law (2022–) covering surprise billing and requiring Good Faith Estimates for self-pay patients; see GFE above.

**OSHA obligations:** Workplace-safety duties including bloodborne-pathogen training, hazard communication, and exposure control plans, annual training cadence.

**Sixty-day rule:** Identified Medicare/Medicaid overpayments must be reported and returned within 60 days (42 U.S.C. § 1320a-7k(d)); retention creates False Claims Act exposure.

**Stark Law:** Physician self-referral prohibition (42 U.S.C. § 1395nn) governing financial relationships with entities you refer to; strict liability, so structure first.

## Business, entity, and deals

**Buy-sell agreement:** The co-owner contract governing exits: death, disability, license loss, departure, deadlock. → [Associates vs. partners](/guides/associates-vs-partners)

**Days in A/R / net collection rate:** Core revenue-cycle KPIs: how long revenue sits between service and cash, and the share of collectible dollars actually collected.

**DSO / MSO / MSA:** Dental/management services organization and the management services agreement binding it to the PC. → [MSO-PC Wiki](https://mso.getlemma.com)

**EBITDA / QoE:** Earnings measure deals are priced on, and the quality-of-earnings review that tests it. → [Buy a practice](/guides/buy-a-practice)

**LOI:** Letter of intent; non-binding on price, binding on exclusivity.

**PC / PLLC:** Professional corporation / professional LLC; the licensee-owned entity form most states require.

**Tail coverage:** Malpractice extension covering claims reported after a claims-made policy ends; decide who pays it at hiring, not departure.

**TI allowance:** Tenant-improvement dollars negotiated into a lease toward build-out.

## Banking

**ACH / addenda:** The payment network payer EFTs ride, and the record within an ACH entry carrying the TRN for reassociation; ask whether a bank surfaces addenda before trusting it with payer deposits.

**FDIC coverage / sweep networks:** \$250k per depositor/bank/category standard coverage ([FDIC](https://www.fdic.gov/resources/deposit-insurance/)); sweep networks extend it by distributing balances across many banks.

**Lockbox:** A dedicated receiving address where payer mail is opened, scanned, and checks deposited on arrival. → [Lockboxes](/concepts/lockboxes)

**Operating / tax / savings structure:** The minimum account architecture. → [Setting up your banking](/start-here/03-setting-up-your-banking)