This glossary defines common insurance and billing terms you may encounter in Blueprint or on insurance documents, and can be used as a quick reference when reviewing claims, payments, or client balances.
Claim
A request sent to an insurance payer for payment of healthcare services provided.
Key things to know:
Includes the provider’s billed charges and service details
Not the same as the allowed or contracted rate
Final reimbursement is determined by the payer, not the billed amount
Co-insurance
A form of cost-sharing where the client pays a percentage of the allowed cost for covered services, and the insurance plan pays the remainder.
Example:
With 20% co-insurance, the client pays 20% and the insurer pays 80% of the allowed amount.
Key things to know:
Applies after the deductible is met
Percentage-based (unlike a flat co-pay)
Continues until the out-of-pocket maximum is reached
Co-pay
A fixed dollar amount a client pays for a covered service, usually at the time of the visit.
Example:
$25 co-pay for an office visit or $10 for a prescription.
Key things to know:
Flat amount that does not change based on service cost
May apply before the deductible is met
Typically counts toward the out-of-pocket maximum
CMS-1500
The standard claim form used to bill insurance for professional and outpatient services.
Key things to know:
Used for both paper and electronic claims
Required by many payers
The electronic version is called the 837-P
CPT Code
A standardized code that describes medical, surgical, or therapeutic services provided to a client.
Key things to know:
Identifies what service was provided
Required for claims submission and processing
Deductible
The amount a client must pay out of pocket each plan year before insurance begins covering most services.
Example:
With a $1,500 deductible, the client pays the first $1,500 of covered services before cost-sharing begins.
Key things to know:
Resets annually
Co-insurance typically applies after the deductible is met
Some services (like preventive care) may be covered before the deductible
Eligibility Check
A verification process that confirms whether a client’s insurance coverage is active and what benefits apply on a specific date of service.
Key things to know:
Confirms coverage status
Provides details on deductibles, co-pays, and co-insurance
Does not guarantee payment
EOB (Explanation of Benefits)
A statement from an insurance payer explaining how a claim was processed.
Key things to know:
Not a bill
Shows what was billed, paid, adjusted, and what the client may owe
Paper version of an ERA
May include a check for payment
ERA (Electronic Remittance Advice)
An electronic document from an insurance payer detailing claim payments, adjustments, and client responsibility.
Key things to know:
Electronic version of an EOB
Used for payment posting and reconciliation
Does not represent the actual transfer of funds
Invoice
A bill sent to the client for their portion of the cost after insurance processes the claim, or for services not billed to insurance.
Key things to know:
Sent directly to the client
Reflects client responsibility (co-pays, deductibles, self-pay balances)
Member ID
The unique identification number assigned to a client by their insurance plan.
Key things to know:
Found on the insurance card
Required for eligibility checks and claims submission
May also be called a Policy ID or Subscriber ID
NPI (National Provider Identifier)
A unique 10-digit number used to identify healthcare providers and organizations in healthcare transactions.
Types:
Type 1: Individual providers
Type 2: Organizations
Key things to know:
Required for billing and claims
Does not change based on location or payer
Payer
The insurance company responsible for processing and paying claims.
Payer ID
A unique identifier assigned to an insurance company for electronic claims and remittance processing.
Key things to know:
Ensures claims are routed to the correct insurer
Required for electronic billing
Place of Service (POS)
A code that identifies where healthcare services were provided (e.g., office, telehealth, facility).
Key things to know:
Impacts claim processing and reimbursement
Must accurately reflect the service location
Rate (Billed Rate)
The amount a provider charges for a service before insurance adjustments.
Key things to know:
Represents the provider’s billed charge
Often differs from the allowed or negotiated rate
Insurance reimbursement is based on the allowed amount, not the billed rate
Superbill
A detailed receipt given to a client that includes the information needed to submit an out-of-network claim to insurance.
Key things to know:
Provided to the client, not the insurer
Used for out-of-network reimbursement
Includes provider details, CPT codes, and diagnosis codes