Glossary

The terms behind a denial, in plain language.

A working reference to the billing and coverage vocabulary that decides whether a claim pays — each term defined clearly and tied to the denial codes and appeal steps it touches.

21

terms defined

Coverage policy

2 terms
LCD vs NCDNational vs. local Medicare coverage policy — and which one governs.Medical necessityThe standard a service must meet to be covered — the core of a CO-50.

Coding

3 terms
NCCI editsThe CMS coding edits that drive most bundling (CO-97) denials.Modifier 59The distinct-service modifier that can unbundle an NCCI edit — when documented.DowncodingPaying a lower-level code than billed — appealable with documentation.

Reimbursement

6 terms
Allowed amountThe most a plan will pay — and why the write-off above it usually isn't a denial.Balance billingBilling the patient the difference — and where the law now prohibits it.Fee scheduleThe list of maximum allowed amounts per code.RVU / RBRVSThe relative-value system behind Medicare physician payment.GPCIThe geographic index that makes the same code pay differently by region.UCRA method for setting out-of-network allowances — and a point you can challenge.

Authorization

3 terms
Prior auth vs precertThree overlapping pre-service terms — untangled.Step therapyThe 'fail first' rule — and how to get an exception.FormularyThe covered-drug list, in tiers — and the exception path.

Remittance

3 terms
EOB vs ERAThe readable statement vs. the electronic 835 — same codes, different format.CARC vs RARCThe reason code vs. the remark code — read them together.RecoupmentClawing back a prior payment — and your right to dispute it.

Process & admin

4 terms
Coordination of benefitsThe rules for which plan pays first — behind a CO-22.MACThe regional contractor that processes Medicare claims and issues LCDs.ABNThe Medicare notice that lets you bill the patient for a non-covered service.IROThe neutral reviewer whose external-review decision binds the plan.

Know the terms. Let Merits build the letter.

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