Bill Review Glossary
The vocabulary, without the marketing.
Twenty-three terms that come up constantly in workers’ compensation and auto casualty bill review, defined the way someone who works on these systems would explain them. Written for the analyst who has just inherited a program and the executive who has to ask a good question about it.
The platform
The system a bill review program runs on, and the part of it that makes the decisions.
- SmartAdvisor®
- A medical bill review platform for workers’ compensation and auto casualty, produced by Mitchell International, Inc. It receives bills, applies pricing rules, and produces both the adjudication result and the Explanation of Review returned to the provider.
- Capstone® Business Decision Manager
- The rules engine inside SmartAdvisor. It decides, bill by bill, which fee schedule applies, which coding edits fire, and whether the bill can complete without a person touching it. How well it is configured is the main determinant of a program’s straight-through rate.
- Claims Examiner Portal
- The interface examiners use to work the bills the rules engine did not complete on its own. Where the rules stop, this is where the human work happens.
How a bill gets priced
The reductions applied to a bill, in the order they usually happen, and the record that has to explain them.
- Fee schedule
- The maximum reimbursement a jurisdiction permits for a given service. Set per state and revised on that state’s own timetable, it is the first reduction applied to most bills — and a rule tuned to last year’s amounts does not announce that it has gone stale.
- Allowed amount
- What a bill is determined to be worth once the rules have been applied: the amount payable, as distinct from what the provider charged.
- Reduction
- The difference between the charged amount and the allowed amount, with a reason attached. Every reduction has to be explainable, because the provider — and sometimes a regulator — will ask.
- Explanation of Review (EOR)
- The document returned to a provider stating how their bill was adjudicated and why each reduction was applied. It is the defensible record of the decision, which is why consistency in the rules matters more than aggressive reduction.
- PPO repricing
- Applying a contracted network rate to a bill, usually after the fee schedule reduction, to capture a further discount the network has negotiated with the provider.
- Network stacking
- Evaluating multiple PPO contracts in priority order and applying the first one that matches. Because it stops at the first match, the deepest available reduction is only applied when it happens to sit at the top of the list.
- Best-contract pricing
- Evaluating every available contracted rate simultaneously and applying the single deepest reduction, rather than stopping at the first match. More savings and one clean network rate per bill, at the cost of a more demanding routing setup.
The codes
What the bill says was done, and the vocabulary the rules have to be written against.
- CPT, HCPCS, ICD-10
- The code sets a bill is written in. CPT and HCPCS describe procedures and supplies; ICD-10 describes diagnoses. All three turn over annually, which means new codes arrive with no rule covering them and retired codes linger in logic nobody revisits.
- Modifier
- A code appended to a procedure code that changes how it should be priced — bilateral, multiple procedure, assistant surgeon, and so on. Modifier logic is a common source of both under-reduction and over-reduction, and it is fiddly enough that it is often the last thing configured properly.
- NPI (National Provider Identifier)
- The ten-digit number identifying a healthcare provider. It is one of several keys used to match provider records, which is why the same provider can arrive in a system as three separate records — one carrying an NPI, one a tax ID, and one a hand-typed name and address.
The workflow
What happens to a bill between arriving and being paid, and where it stops.
- Straight-through processing (STP)
- The share of bills that go from intake to a completed adjudication without a person touching them. In a configured program, 50–70% is the normal range rather than the ceiling — the gap between that and what is achievable is usually rule work.
- Pend
- Holding a bill in a queue instead of completing it, because a rule requires review or because information is missing. Pend volume rising for one specific reason is usually a rule that stopped matching, which is why it is worth watching by reason rather than in total.
- Bill capture
- Turning paper or scanned bills into structured data a platform can price, including matching each bill to the right claim and the right provider. The matching is the hard part, not the reading.
- Duplicate detection
- Identifying a bill that has already been submitted, in whole or in part. Detection quality drifts over time as provider and claim data quality changes, so a rate that was good at go-live is not evidence about today.
- Jurisdiction
- The state whose workers’ compensation rules govern a claim. Nearly everything downstream depends on it — fee schedule, reporting requirements, reimbursement rules — so a program that derives jurisdiction from incomplete data produces correct rules and wrong answers.
Moving the data
How bills and results travel between the systems involved.
- EDI 837
- The X12 standard transaction for sending healthcare claim data electronically. In bill review it is the usual format for moving bill data between claims systems, bill review platforms, and external repricing networks.
- Bi-directional exchange
- An integration that returns results as well as sending data — repricing outcomes, payment detail, status. Scoping an integration as a one-way file drop is quicker to agree to and more expensive to retrofit once the program needs the return path.
Who is involved
The organizations that run, administer, or manage a bill review program.
- TPA (third-party administrator)
- A firm that administers claims on behalf of a carrier or a self-insured employer, often including the bill review function.
- MCO (managed care organization)
- An organization managing the medical side of claims — network access, utilization review, and care coordination.
- Auto casualty
- Auto injury claims: personal injury protection, medical payments, and bodily injury. Medical bills are reviewed here too, but under a different set of rules than workers’ compensation, which is why a program handling both needs its rules separated cleanly.
Missing something you had to look up? Tell us and it goes in. A glossary is only useful if it covers the term that actually stopped you.
Inherited a program you didn’t configure?
That's the normal starting point. A rules audit tells you what the configuration is actually doing before you have to defend it.