Glossary

Plain-English definitions of the terms you will encounter as a tenant user. If you are platform staff, the Platform Admin Glossary covers infrastructure terms (tenant DB, db_server, etc.) that you do not need to manage from this app.

People and roles

Term	Meaning
Tenant admin	A staff member at your organization who can manage payers, rules, fee schedules, users, and trading partner credentials.
Billing clerk	Staff who works the claims, denials, and receivables desk. Day-to-day claim build, submit, post, appeal.
Clinician / supervisor	Staff who delivers services and is responsible for taking attendance, entering charges, and requesting authorizations.
Operations analyst	Staff who watches the dashboards, triages issues, and audits PHI access.
PLATFORM_ADMIN	A MedSuite engineer with cross-tenant rights. You will rarely see one; they appear in the audit log only when actively impersonating into your tenant for support.

Members and coverage

Term	Meaning
Member	A person receiving services. Carries demographics, identifiers, and one or more coverage policies.
Coverage policy	A specific insurance plan a member is enrolled in. A member can have many — primary, secondary, tertiary.
Dual-eligible	A member with both Medicare and Medicaid. Medicaid is payer of last resort (see COB & dual-eligibility).
Eligibility	Real-time confirmation (via 270/271) that a payer recognizes the member and will cover services.
Enrollment	The dated relationship between a member and a coverage policy.

Authorizations

Term	Meaning
Authorization (auth)	A pre-approval from a payer to deliver a specified service for a specified number of units in a specified window.
Auth status	Lifecycle state: DRAFT → SUBMITTED → APPROVED / DENIED / PENDED → CANCELED / EXPIRED.
278 transaction	The X12 electronic format used to request an auth and receive the response.
Auth utilization	How much of an approved auth has been used. Visible on member detail and the auth detail page.

Charges and claims

Term	Meaning
Encounter	A point-in-time record of a clinical visit, group session, or other service event.
Charge	The billing line generated from an encounter. Carries CPT/HCPCS, modifiers, units, and a fee.
Claim	A grouped set of charges submitted to a payer.
Claim status	CREATED → BUILT → SUBMITTED → ACK_RECEIVED → ACCEPTED / REJECTED → PAID / DENIED. See Status reference.
837	The X12 format for claims. 837P = professional, 837I = institutional.
277CA	The X12 acknowledgment that says whether the payer accepted the file.
999	The X12 functional acknowledgment — file-level pass/fail.

Receivables and remittances

Term	Meaning
ERA / 835	The X12 Electronic Remittance Advice. The payer's payment file — what they paid, what they adjusted, what they denied.
EOB	Explanation of Benefits — the human-readable analog of an ERA.
Posting	The act of applying ERA lines to claims and updating the AR.
Variance	A claim line where the posted amount disagrees with the expected amount. Must be resolved before the receivable closes.
CARC	Claim Adjustment Reason Code — the standardized reason a payer reduced/denied a line.
RARC	Remittance Advice Remark Code — supplemental detail accompanying a CARC.

Denials and corrections

Term	Meaning
Denial	A claim or line marked unpayable by the payer.
Auto-correction	An automated rebill flow that fixes specific denial reasons (CO-4 modifier, CO-16 missing info, CO-29 timely, etc.) and resubmits the claim without staff intervention.
Appeal	A formal customer-driven request for the payer to reconsider a denial.
Rebill	A fresh submission of a claim, replacing the prior submission.

Coordination of Benefits

Term	Meaning
COB	Coordination of Benefits — the rules for which payer pays first when a member has multiple coverages.
Primary / secondary / tertiary	The order in which payers process the claim. The platform automatically generates secondary/tertiary claims using the primary's adjustments.
Waterfall	The chain of secondary → tertiary → … claims that fall out from a primary remittance.
MSP matrix	Medicare Secondary Payer rules. Codified by CMS; the platform applies them automatically.
Medicaid last resort	Federal rule: Medicaid never pays before any other available coverage. The platform enforces this.

Configuration

Term	Meaning
Payer	An insurance entity that pays claims (state Medicaid, commercial carrier, Medicare).
Program	A specific product a payer offers (e.g. "Anthem PPO", "Ohio Medicaid IDD Waiver").
Contract	A negotiated agreement with a payer that affects rates, filing windows, and authorizations.
Fee schedule	A table of CPT/HCPCS codes mapped to allowed amounts. Optionally tied to a contract.
Modifier	A 2-character suffix on a CPT/HCPCS code that adjusts pricing or signals context (e.g., HQ = group, U1 = waiver tier 1).
Rule set	A versioned bundle of YAML rules the engine applies during scrub (see Edit rules engine YAML).
Modifier injection rule	Configuration that auto-adds a modifier to charges that match a pattern.

Ingestion

Term	Meaning
Feed	An inbound channel that delivers data files (member rosters, charge files) into the platform. SFTP polling or push API.
Mapping definition	A YAML spec that transforms raw inbound rows into canonical entities. Versioned (DRAFT → SUBMITTED → ACTIVE → ARCHIVED).
Batch	One inbound file's worth of records, with a status (RECEIVED → PARSED → MAPPED → COMPLETED / FAILED).
Push API key	Bearer credential used by an outside system to push records into a feed in real time.

EVV

Term	Meaning
EVV	Electronic Visit Verification. Federally mandated for Medicaid personal-care and home-health services.
Visit	A single EVV-recorded service event with check-in and check-out.
Exception	A visit that failed validation (geofence, time window, member mismatch).
EVV source	A registered upstream EVV vendor whose visits flow into your tenant.

EDI / Trading partners

Term	Meaning
Trading partner	An EDI counterparty — clearinghouse, state Medicaid MMIS, commercial payer.
Companion guide	Per-state or per-payer rules layered on top of the X12 standard. The platform applies your enrolled guides automatically.
Routing rule	Configuration that decides which trading partner handles a given claim.
SFTP	Secure File Transfer Protocol. The most common transport for batch EDI.

See also

• Status reference — exact lifecycle states for claims, denials, and authorizations.
• CARC/RARC quick-reference — how to read a denial code at a glance.