Glossary

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270/271: An inquiry (270) to the patient's health insurance company to obtain current coverage information and to see if a patient has valid health insurance coverage. (271) is the response or return file from the carrier or medical claims clearing house to the inquiry. The ClearGage Payment Accelerator can receive this information from either a practice management system (PMS) or any third party clearing house.

276/277: An inquiry to obtain information regarding an 837 submitted to a payer to get the status of a particular claim. (277) is the response or return file data to the inquiry. The ClearGage Payment Accelerator can receive this information from either a practice management system (PMS) or any third party clearing house.

835: An explanation of benefits and an amount of payment paid to a physician in response to a claim. The ClearGage Payment Accelerator can receive this information from either a practice management system (PMS) or any third party clearing house.

837: A claim submitted to an insurance carrier for payment for a patient visit. The ClearGage Payment Accelerator can receive this information from either a practice management system (PMS) or any third party clearing house.

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A

ACH: "Automated Clearing House" – The ClearGage Accelerator facilitates the receipt of payments electronically from a patient's checking and savings bank account directly into the provider's bank account.

Adjudication: The determination of a carriers or patient's liability and, or financial responsibility, after a medical claim is applied to the patient's insurance benefits.

Affiliated Provider: A healthcare provider or facility that is part of the patient's insurance network and who has a formal arrangement to provide services to the patient.

Allowed Charge: The approved charge amount a third party payer allows for services of a provider. This usually does not match what the provider gets paid by the third party (due to co-payments or deductibles).

Allowable Costs: Covered expenses within a given health plan.

ANSI: The American National Standards Institute. A national organization founded to develop voluntary business and transaction standards in the United States.

Application Integrators: Software that transparently provides application-to-application communication, primarily through data conversion and transmission, while eliminating the need for custom programming.

Assignment of Benefits: Method used when a claimant directs that a payment be made directly to the healthcare provider by the health plan.

Authorization: Any document designating any permission. In healthcare, authorization may refer to "authorization to disclose" private information, "authorization to treat" or "authorization to pay", as in "pre-authorization" required by many insurance companies and health plans.

Automated Clearing House (ACH): An electronic network for financial transactions in the United States. The ClearGage Accelerator facilitates the receipt of payments electronically from a patient's checking and savings bank account directly into the provider's bank account.

Automated Payment: A scheduled financial payment from a patient's credit, debit or bank accounted directly into the provider's bank account.

Automated Remittance: The ability to automatically post HIPAA compliant file formats into your practice management system.

Availity: a joint venture with Humana, Inc and Blue Cross and Blue Shield of Florida and one of the largest EDI medical clearinghouses in the nation-processing more than 600 million transactions annually.

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B

Balance Billing: The practice of billing a patient for the amounts remaining after their insurer has adjudicated the claim and their payments to the provider have been made.

Batch: A collection of pending financial transactions. Batches can be submitted manually by the provider, or set to submit automatically only batches that have been submitted can be reviewed.

Batch ID: After settlement, each batch is assigned an identification number by ClearGage. Providers can click on the Batch ID links to review transactions in a particular batch. Providers can access batches for review by clicking the "Review batches" link in the ClearGage application.

Batch Processing: Batches are processed nightly by default (see automated daily batch submission). Providers can also send batches manually. Batches are submitted to your merchant account processor for settlement.

Beneficiary Liability: The amount beneficiaries must pay providers for covered services. Liabilities include copayments, deductibles, and balance billing amounts.

Benefits: Benefits are specific areas of Plan coverage's, i.e., outpatient visits, hospitalization and so forth, that makes up the range of medical services that a payer markets to its subscribers.

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C

Card (Bank Account) on File: The ClearGage Accelerator allows you to store credit/debit and bank account information in our PCI compliant application.

Card Not Present: A transaction where the cardholder does not physically provide the card to the provider for processing (online, phone, fax orders). These transactions are typically charged a higher discount rate due to the increased risk of fraud.

Card Present: A transaction where the cardholder presents the card to the merchant for payment as demonstrated by swiping the card through a point of sale (POS) terminal or imprinting the credit card. Lower fees are associated with card present transactions as these transactions have a lower incidence of fraud.

Chargeback: The process initiated by a cardholder to dispute a transaction through their issuing bank or credit card association.

Charge Master: Also known as a chargemaster or CDM, contains a provider's prices of all services, goods, and procedures for which a separate charge exists. It is used to generate a patient's bill.

Claim: A request by a patient (or his or her provider) to that individual's insurance company to pay for services obtained from a healthcare professional or an itemized statement of healthcare services and their costs provided by a hospital, physician's office, or other provider facility. Claims are submitted to the insurer or managed care plan by either the patient or the provider for payment of the costs incurred.

Claim Status Codes: A national administrative code set that identifies the status of healthcare claims. This code set is used in the X12N 277 Claim Status Inquiry and Response transaction, and is maintained by the Healthcare Code Maintenance Committee.

Claim Verification Service: Electronically verify eligibility, coverage for medical claims.

ClearCalc™: ClearGage's proprietary tool that can calculate a patient's liability at the point of care and prior to services being rendered.

ClearGage Payment Accelerator™: ClearGage's web-based, patient friendly liability estimator and payment tool that enables healthcare providers to increase their cash collections and reduce bad debt. The tool is more cost effective than traditional methods of billing and collections and can dramatically speed up the revenue cycle by as much as 60 days.

ClearGage Patient Payment Portal: A simple, convenient and secure way to pay online with credit, debit or the increasingly common varieties of healthcare accounts such as HSA, FSA or HRA.

Co-Insurance (Coinsurance): A cost-sharing requirement under a health insurance policy that provides that the insured will assume a portion or percentage of the costs of covered services.

Collection: The collection of receivables associated with the medical care of an individual, including third party payers and patient liabilities.

Consumer Driven Healthcare (CDH): Health insurance plans that allow patients to use personal Health Savings Accounts (HSAs), Health Reimbursement Arrangements (HRAs), or similar medical payment products to pay routine healthcare expenses directly, while a high-deductible health insurance policy protects them from catastrophic medical expenses.

Credit Card Associations: Visa, MasterCard International, American Express, Discover (Novus).

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D

Data Mapping: The process of matching two disparate information systems or data bases by mapping one set of data elements or individual code values to their closest equivalents in the other system.

Data Warehouse: A specific database (or set of databases) containing data from many sources that are linked by a common subject (e.g., a plan patient).

Deductibles: Amounts required to be paid by the insured under a health insurance contract, before benefits become payable. Different components of a health plan may have separate deductibles. Usually expressed in terms of an "annual" amount.

Disallowance: When a payer declines to pay for all or part of a claim submitted for payment.

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E

Electronic Claim: A digital representation of a medical bill generated by a provider or the provider's billing agent for submission electronically to a health insurance payer.

Electronic Data Interchange (EDI): The automated exchange of data and documents in a standardized format. In healthcare, some common uses of this technology include claims submission and payment, eligibility, and referral authorization. Refers to the exchange of routine business transactions from one computer to another in a standard format, using standard communications protocols.

Electronic Data Interchange (EDI) Translator: Used in electronic claims and medical record transmissions, this is a software tool for accepting an EDI transmission and converting the data into another format, or for converting a non-EDI data file into an EDI format for transmission. The ClearGage Payment Accelerator has a robust EDI Translator that enables the application to communicate with any HL7 practice management system, many accounting software systems or other HIPAA compliant trading partner.

Electronic Funds Transfer (EFT): payments electronically from a patient's checking and savings bank account directly into the providers bank account. (See ACH.)

Electronic Remittance Advice: Any of several electronic formats for explaining the payments of healthcare claims.

Eligibility: the process of confirming the patient's ability to receive benefits.

Eligibility Verification Service: An application that can verify a patient's insurance eligibility in real-time. The ClearGage Payment Accelerator™ supports real-time eligibility confirmation through the direct interface of any HIPAA compliant clearing house or HL7 compliant practice management system.

Exclusions: Conditions or situations not considered covered under contract or plan.

Explanation of Benefits (EOB): The statement to the patient or subscriber from an insurance carrier that explains the benefits and payments surrounding a medical encounter.

Electronic Payment Gateway: An e-commerce application that authorizes payments for to a business. The ClearGage Payment Accelerator™ is a payment gateway consisting of hardware and software that connects patient payments to the provider's payment processor.

Electronic Remittance Advice (ERA): The electronic notification of payment from a patient's carrier.

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F

Fee Disclosure: Physicians and caregivers discussing their charges with patients prior to treatment.

Fee Schedule: A listing of accepted fees or established allowances for specified medical procedures. As used in healthcare plans, it usually represents the maximum amounts the program will pay for the specified procedures.

Flexible Spending Account (FSA): Allows an employee to set aside a portion of his or her pre-tax earnings to pay for qualified expenses including medical.

Financial Services Modernization Act: Legislation that allows convergence among the traditionally separate components of the financial services industry - banks, securities firms, and insurance companies. Also known as the Gramm-Leach-Bliley (GLB) Act.

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H

Health Savings Account (HSA): A tax-advantaged medical savings account.

Healthcare Clearinghouse: An entity that processes or facilitates the processing of information using HIPAA compliant file layouts. (See Data Warehouse).

Healthcare Payment Solutions: The use of technology, communication tools, and processes to enhance revenue collections in the most cost effective manner. The ClearGage Payment Accelerator is a comprehensive healthcare payment solution.

Healthestatement: ClearGage's secure and HIPAA compliant proprietary patient messaging system utilizing both email and SMS text messaging.

Health Reimbursement Accounts (HRA): Partially self-funded means the employer pays a predetermined portion of medical claims up to a cap.

Healthcare Revenue Cycle: Specific to the healthcare industry, the healthcare revenue cycle starts at the time services are rendered.

Health Insurance Portability and Accountability Act of 1996 (HIPAA): A Federal law that allows persons to qualify immediately for comparable health insurance coverage when they change their employment relationships. This legislation sets a precedent for Federal involvement in insurance regulation. It sets minimum standards for regulation of the small group insurance market and for a set group in the individual insurance market in the area of portability and availability of health insurance. As a result of this law, hospitals, doctors and insurance companies are now required to share patient medical records and personal information on a wider basis.

HIPAA Compliant: A set of privacy regulations established by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) that require healthcare organizations and their business associates to develop and follow procedures that ensure the confidentiality and security of protected health information (PHI) when it is transferred, received, handled, or shared. ClearGage and the ClearGage Payment Accelerator™ and all of our business associates are HIPAA compliant.

HL7: is an all-volunteer, not-for-profit organization involved in the development of international healthcare standards. "HL7" is also used to refer to some of the specific standards created by the organization. ClearGage and the ClearGage Payment Accelerator can work with any PMS that is HL7 compliant.

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I

Informed Consent: Refers to requirements (by HIPAA, Medicare, State and Federal Laws) that healthcare providers and researchers explain the purposes, risks, benefits, confidentiality protections, financial costs and other relevant aspects of the provision of medical care, a specific procedure or participation in medical research.

Insurance Eligibility Tool: An application that can verify a patient's insurance eligibility in real-time. The ClearGage Payment Accelerator supports real-time eligibility confirmation through the direct interface of any HIPAA compliant medical clearinghouse or HL7 compliant practice management system.

Interface: A means of communication between two computer systems, two software applications or two modules.

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J

J-Codes: A subset of the HCPCS Level II code set with a high-order value of "J" that has been used to identify certain drugs and other items.

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M

Maximum Defined Data Set: Under HIPAA, this is all of the required data elements for a particular standard based on a specific implementation specification. An entity creating a transaction is free to include whatever data any receiver might want or need. The recipient is free to ignore any portion of the data that is not needed to conduct their part of the associated business transaction, unless the inessential data is needed for coordination of benefits.

Maximum Out-of-Pocket Expenses: Limit on total number of co-payments or limit on total cost of deductibles and co-insurance under a benefit plan.

Medical Billing Company: A third party that is contracted with a medical provider to handle most aspects of the revenue cycle including billing and collections.

Medical Claims Clearing House: An entity that processes or facilitates the processing of information using HIPAA compliant file layouts. (See Healthcare Clearinghouse).

Merchant Account: A relationship between a merchant account provider and a merchant for the purpose of conducting payment processing though a individuals credit cards and/or bank accounts. ClearGage can arrange for a merchant account from any of its partnered merchant account providers.

Merchant Account Provider: A merchant bank that facilitates authorizing and settling online credit card payments and ACH's of patients for merchants. ClearGage can work with most merchant account providers.

Merchant Identification Number (MID): The unique number assigned by the merchant account provider to a merchant.

Merchant Processors: A payment processor is a company (often a third party) appointed by a merchant to handle credit card transactions for merchant account providers.

"MOTO": Mail Order or Telephone Order; refers to the ability for a provider to run a financial transaction from a patient without the patient being physically present.

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O

Out-of-Network Benefits: With most HMOs, a patient cannot have any services reimbursed if provided by a hospital or doctor who is not in the network. With PPOs and other managed care organizations, a provision may also exist for reimbursement of "out-of-network" providers. Usually this will involve higher co-payment or a lower reimbursement amount.

Out-of-Pocket Expenses, Out of Pocket Costs: Dollar amounts set by healthcare insurance companies that limit the amount a patient has to pay out of his own pocket for particular healthcare services during a particular time period.

Out-of-Pocket Limit: A cap placed on out of pocket costs, after which benefits increase to provide full coverage for the rest of the year. It is a stated dollar amount set by the insurance company, in addition to regular premiums.

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P

Participating Provider: Simply refers to a provider under a contract with a health plan.

Patient Liability: The dollar amount that an insured patient is legally obligated to pay for services rendered by a provider. These may include co-payments, deductibles and payments for uncovered services.

Patient Payment Estimator: A tool that enables you to understand the patient's responsibility for co-pays, co-insurance and deductibles, specific to the services you are providing and specific to your contract with the patient's health plan. ClearCalc™ is a patient payment estimator.

Payer: Third-party that pays providers for healthcare services rendered in accordance with a contract between the health plan and patient and the health plan and the provider.

Payment Discounts: Allowances or reductions to a basic price of goods or services. The ClearGage Payment Accelerator™ allows you to provide discounts if so desired.

Payment Gateway: The ClearGage Accelerator is an e-commerce application that authorizes payments for to a business. The ClearGage Payment Accelerator is a payment gateway consisting of hardware and software that connects patient payments to the provider's payment processor.

Payment Plan Service Fees: Fees established by the provider to cover the costs of establishing a payment plan with patients. The ClearGage Payment Accelerator™ allows for a user to establish these fees or not charge them at all.

Payment Schedules: The ClearGage Payment Accelerator™ allows for you to set up payment schedules surrounding payment plans and recurring transactions. Payment schedules can be daily, weekly, ever two weeks and monthly.

Payments on File: A ClearGage Payment Accelerator™ feature that allows you to securely store payment information and schedule future payments.

PCI Compliant: Something that satisfies the security requirements outlined by the Payment Card Industry (PCI). ClearGage is a Level One Compliant Service Provider with the PCI Data Security Standard.

Payment Card Industry (PCI) Data Security Standard: The Payment Card Industry Data Security Standard is a worldwide information security standard assembled by the Payment Card Industry Security Standards Council (PCI SSC). The standard was created to help organizations that process card payments prevent credit card fraud through increased controls around data and its exposure to compromise.

Point of Sale (POS): The place where a sale occurs in a physical retail space. POS Sales are conducted most often through swipe terminals.

Practice Management System (PMS): A category of software that deals with the day-to-day operations of a medical practice. Such software frequently allows users to capture patient demographics, schedule appointments, maintain lists of insurance payers, perform billing tasks, and generate reports. The ClearGage Payment Accelerator™ can interface with any HL7 compliant software system.

Price Transparency: the process by which a provider fully discloses to the patient the full extent of their financial responsibilities for procedures prior to the delivery of care.

Protected Health Information: Under HIPAA, this refers to individually identifiable health information transmitted or maintained in any form.

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R

Recurring Payments: Ideal for those patients with high patient liabilities, the ClearGage Accelerator easily establishing recurring debits from a patient's credit/debit or bank accounts.

Refund Transaction: Use the payment Accelerator to refund payments to patients banking accounts or credit/debit cards.

Remittance: A monetary payment transferred by a customer to a business.

Resource Center: The ClearGage Payment Accelerator's comprehensive training center with on-line videos for all application modules.

Revenue Cycle Management: The process by which entities manage their billing and collections for services rendered including billing, statement processing, payments and posting balances.

Revenue Cycle Technology: Any form of technology that can be applied to drive revenue cycle results.

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S

Self-Pay Patients: Patients that are wholly responsible for all of the costs surrounding their medical treatment.

SSL (Secure Sockets Layer): The industry standard encryption system that allows for secure transmission of data between buyers and merchant sites.

Subscriber: Employment group or individual that contracts with an insurer for medical services.

Swipe Device: A device that reads the magnetic strip on the back of financial and healthcare cards. The ClearGage Payment Accelerator™ can be adapted to use a card swipe for payment processing.

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T

Termination Date: Date that a group contract expires or an individual is no longer eligible for benefits.

Third-Party Payment: Payment by a financial agent such as an HMO, insurance company or government rather than direct payment by the patient for medical care services.

Third-Party Payer: Any organization, public or private that pays or insures health or medical expenses on behalf of beneficiaries or subscribers.

Transaction: Usually refers to the exchange of information for administrative or financial purposes such as health insurance claims or payment. Under HIPAA, this is the exchange of information between two parties to carry out financial or administrative activities related to healthcare.

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W

Waiting Periods: The length of time an individual must wait to become eligible for benefits for a specific condition after overall coverage has begun.

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