C
Capitation A fixed payment paid per patient enrolled over a defined period of time, paid to a health plan or provider. This covers the costs associated with the patient’s health care services.
Carrier The insurance company or ‘carrier’ the patient has a contract with to provide health insurance.
Category Codes
- Category I Codes Codes for medical procedures or services identified by the 5 digit CPT Code.
- Category II Codes Optional performance measurement tracking codes which are numeric with a letter as the last digit (example: 9763B).
- Category III Codes Temporary codes assigned for collecting data which are numeric followed by a letter in the last digit (example: 5467U).
CHAMPUS Civilian Health and Medical Program of the Uniformed Services. Recently renamed TRICARE. Federal health insurance for active duty military, National Guard and Reserve, retirees, their families, and survivors.
Clean Claim A complete submitted insurance claim that has all the necessary correct information without any omissions or mistakes that allows it to be processed and paid promptly.
Clearinghouse A service that transmits claims to insurance carriers. Prior to submitting claims the clearinghouse scrubs claims and checks for errors.
CMS Centers for Medicaid and Medicare Services. Federal agency which administers Medicare, Medicaid, HIPAA, and other health programs.
CMS 1500 Medical claim form established by CMS to submit paper claims to Medicare and Medicaid. Most commercial insurance carriers also require paper claims be submitted on CMS-1500’s.
Coding Taking the doctor’s notes from a patient visit and translating them into the proper diagnosis (ICD-10 code) and treatment medical billing codes such as CPT codes.
Co-Insurance Percentage or amount defined in the insurance plan for which the patient is responsible. Most plans have a ratio of 90/10, 80/20, 70/30, etc.
Collection Ratio The ratio of the payments received to the total amount of money owed on the provider’s accounts.
Contractual Adjustment The amount of charges a provider or hospital agrees to write off and not charge the patient per the contract terms with the insurance company.