Reeve · Glossary

The terms that decide whether a delivered visit becomes a collected dollar.

Plain definitions for the words that show up on your remittance, your authorization, and your denial reports. No jargon for its own sake, and nothing you cannot verify against a payer manual.

Authorization (prior auth): The payer's advance approval of a specific service, unit count, and date span for a specific client. A visit delivered outside the authorized span or beyond the unit ceiling is typically denied or later recouped.
Units: The billing quantity attached to a home care service, usually 15 minutes for personal care and hourly for homemaker. Every authorization, claim line, and remittance is denominated in units, so unit math is where most silent discrepancies live.
EVV (Electronic Visit Verification): A federally required system, mandated by the 21st Century Cures Act, that captures who delivered a Medicaid personal care or home health visit, where and when it started and ended, the service performed, and the client served. A visit not captured in EVV cannot be paid.
Timely filing limit: The payer-specific deadline, measured from the date of service, by which a clean claim must be received. Most Medicaid programs allow 90 to 365 days, and most require a resubmission every 60 to 90 days after a denial to keep the claim inside the window.
Clawback: A payer or state Medicaid recovery of money already paid to the agency, taken back on a future remittance after a post-payment audit finds a claim did not meet documentation, EVV, or authorization requirements.
Recoupment: The mechanical act of offsetting a prior overpayment against the next remittance. Clawback is the audit finding; recoupment is how the money actually leaves the bank. On the 835 it appears as a negative adjustment against unrelated claims.
Denial vs rejection: A rejection is a claim that never entered adjudication because it failed a format or eligibility edit at the clearinghouse or front door, and it does not count against the timely-filing window. A denial is a claim that adjudicated and was refused payment, carries a CARC and often a RARC, and does count against the window.
Modifier: A two-character code appended to a procedure code that tells the payer which rate tier applies, for example credential level, live-in versus hourly, or day of week. A wrong modifier often adjudicates as valid and pays at a lower rate rather than denying.
Rate or fee schedule: The payer's published price per procedure code and modifier combination for a given date span. A contracted rate that changes mid-year is one of the most common sources of silent underpayment, because the EMR keeps billing the old rate until someone reconciles the first remittance under the new schedule.
Delivered but unbilled: A visit that was scheduled, delivered, and typically paid to the caregiver, but that never became a submitted claim. These visits do not appear on denial reports, so they age quietly toward the timely-filing wall and become permanent write-offs when the window closes.
Reconciliation: The line-by-line comparison of the four numbers that must agree on every visit: what the payer authorized, what caregivers delivered on EVV, what went out on the claim, and what actually paid. Reeve's Margin Review is a reconciliation on a single closed period.
Managed care organization (MCO): A private health plan that a state Medicaid program contracts to administer benefits for a defined population. Each MCO has its own provider portal, fee schedule, prior-auth process, and timely-filing window, which is why one agency can have five different billing workflows for the same service.
837P claim: The ANSI X12 837 Professional transaction, the standard electronic format for outpatient and personal-care claims. Every claim your clearinghouse sends to Medicaid or an MCO is an 837P under the hood.
Remittance (835): The payer's line-by-line accounting for a batch of claims, delivered as an ANSI 835 electronic remittance or a paper Explanation of Benefits, showing what was billed, what was paid, what was adjusted, and the CARC and RARC for each adjustment.

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