Medical Billing and Epic Clarity Fundamentals

A complete set of vocabulary flashcards based on lecture notes covering healthcare revenue cycle terminology and Epic Clarity database schemas.

Guarantor

The person whose wallet pays the bill, even if they're not the one who got treated. Like a parent paying for their kid's doctor visit.

Subscriber

The person whose name is actually on the insurance card.

Payer

The insurance company. The one who's supposed to send money.

Plan

The specific insurance "package" you're on, like choosing the Deluxe or Basic option from the same company.

Coverage

The unique combo of "this patient + this payer + this plan + this subscriber." Like a specific ticket that says who's covered, how, and through whom.

Filing Order

The order in which a patient's coverages get billed if they have more than one, primary first, then secondary, etc.

Chargemaster

The hospital's sticker price list, not what anyone actually expects to get paid.

Contractual Adjustment

The pre-agreed discount between the sticker price and what insurance actually owes. Expected. Not a mistake.

Denial

Insurance saying "nope, not paying this," and someone has to find out why and fight it or not.

Underpayment (Variance)

Insurance paid, but less than they promised in the contract. This is money someone needs to chase down.

A/R (Accounts Receivable)

Money that's owed to the hospital but hasn't shown up yet.

A/R Aging

Sorting unpaid bills by how long they've been unpaid, like a "how stale is this" clock.

Bad Debt

When the patient could pay (or was expected to) but doesn't, and the hospital gives up chasing them directly.

Charity Care

The hospital deciding upfront, "this person truly can't afford it," and not charging them at all.

Timely Filing

The deadline to submit a claim. Miss it, and it's basically dead, no do-overs.

COB (Coordination of Benefits)

The rulebook for figuring out which insurance pays first when a patient has two.

Prior Authorization

Insurance's permission slip, you need their "yes" before some treatments, or they won't pay after the fact.

EOB (Explanation of Benefits)

The letter insurance sends explaining what they paid, what they didn't, and why.

Professional Billing (PB)

The billing system that tracks and pays for the DOCTOR'S work, like the exam or procedure the physician personally did.

Hospital Billing (HB)

The billing system that tracks and pays for the FACILITY'S work, like the room, supplies, meds, and machines.

Charge Router

The Epic traffic cop that looks at each charge from a visit and sends it to the correct billing system, PB or HB.

Matching

A Professional Billing concept where a specific payment gets linked back to the specific charge it paid for.

Liability Bucket

How Hospital Billing organizes payments when charges get rolled up into claim lines instead of matched one-to-one.

Encounter

A single visit or interaction where care was given, like one office visit or one hospital stay.

Hospital Account (HAR)

The Epic "hub" record that ties together the guarantor, coverage, and encounter(s) for a hospital bill.

PATIENT (Clarity table)

The Clarity table with one row for every patient, storing basic demographic info.

ACCOUNT (Clarity table)

The Clarity table for guarantor info. Also stores PB balances ($TOTAL_BALANCE$) and HB balances ($HB_BALANCE$) on the same table.

COVERAGE (Clarity table)

The Clarity table storing the payer + plan + subscriber combination used for billing.

CLARITY_EPM (Clarity table)

The Clarity table that stores payer details.

CLARITY_EPP (Clarity table)

The Clarity table that stores benefit plan details.

ARPB_TRANSACTIONS (Clarity table)

The core Professional Billing transaction table (charges, payments, adjustments for PB).

HSP_TRANSACTIONS (Clarity table)

The core Hospital Billing transaction table (charges, payments, adjustments for HB).

ACCT_GUAR_PAT_INFO (Clarity table)

The Clarity table with one row for every patient-guarantor relationship.

COVERAGE_MEMBER_LIST (Clarity table)

The Clarity table listing members (people) attached to a given coverage.

V_COVERAGE_PAYOR_PLAN (Clarity view)

A Clarity view that shows the payer and plan names for each coverage, convenient for reporting.