SuperDial Glossary

Agentic AI

AI systems that can independently complete multi-step tasks without constant human input. Agentic AI learns complex processes through experience and can manage them end-to-end.

For example, an agentic AI programmed for multistep insurance tasks can verify a patient’s benefits, submit a claim, and check their claim status without any back-and-forth between human operators.

Go deeper: How Agentic AI Is Shaping the Future of Provider-Payor Collaboration

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Appeal Automation

Technology that prepares, submits, and tracks appeals for denied claims, reducing turnaround times and manual paperwork.

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Automated Benefits Discovery

The process of uncovering a patient’s active insurance coverage using automated outreach (often phone-based), helping reduce eligibility-related denials.

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Automated Eligibility Checks

Tools that confirm a patient’s active coverage, copays, deductibles, and plan rules instantly through electronic or phone-based verification.

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Automated Prior Authorization Management

Software that handles the entire prior auth lifecycle, from initiating requests to completing follow-ups, saving staff hours each week.

Go deeper: Why Healthcare Providers Are Automating Prior Authorization Calls

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Automated Verification Calls

AI-driven calls to payors that retrieve detailed benefit data, authorization requirements, or claim updates, often with higher accuracy than portal-based checks.

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Balance Billing 

Balance billing happens when a provider bills a patient for the difference between the provider’s charge and the insurer’s allowed amount. For example, if a provider charges $200 and the insurer’s allowed amount is $140, the provider may bill the patient the $60 difference — unless federal or state law (for example the No Surprises Act) prohibits balance billing for that service.

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Claim Correction Automation

Tools that detect missing codes, documentation errors, or formatting issues before submission, helping prevent denials.

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Claim Followup Automation

AI or workflow engines that systematically check claim status with payors and alert RCM teams when action is required.

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Clean Claim Rate Optimization

Processes or tools that improve the percentage of claims accepted on the first submission, reducing rework and speeding up reimbursement.

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Coding Quality Audits

Regular reviews—often supported by AI—to ensure diagnosis and procedure codes are accurate, compliant, and optimized for reimbursement.

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Coinsurance

Coinsurance is the percentage of a covered cost a patient pays after meeting their deductible. For example, with 20% coinsurance on a $200 charge, the patient pays $40 and the insurer pays $160 — once the deductible has been met. 

Coinsurance payments generally count toward the plan’s out-of-pocket maximum, but plan details determine how deductibles, copays, and coinsurance interact.

Go deeper: The Complete Guide to Out-of-Network Reimbursement

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Copayment

A copayment is a fixed amount a patient pays for a covered healthcare service at the time of care. Often referred to as a "copay," it generally does not count toward a patient’s deductible but does count toward the out-of-pocket maximum. But plan details vary by plan.

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Cost Sharing

Cost sharing refers to the portion of healthcare costs split between the patient and their insurer, typically through copays, deductibles, and coinsurance.

For instance, even if a patient has met their deductible, they may still owe a fixed copay, or a percentage of the cost in coinsurance, sharing the total cost with their insurer. 

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Courtesy Billing

Courtesy billing is when a provider files an insurance claim on a patient’s behalf even though the provider is out-of-network, or otherwise assists the patient by submitting charges directly to the payor as a courtesy.

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Current Procedural Terminology (CPT) Codes

Current Procedural Terminology (CPT) codes are the standard language health care professionals and insurers use to denote medical goods and services. They’re used when filing claims to let insurers know what items or services a patient has received.

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Deductible

A deductible is the amount an insured party pays for covered healthcare services before the insurance plan starts to pay.

Let's say your health plan has a $2000 deductible. This means you pay the first $2000 of covered services each year before your insurance kicks in. This is often referred to as having "met" your deductible. 

Certain services, like preventive visits, are typically covered by insurance before you meet your deductible. After you have met your deductible, you usually pay only a copayment or coinsurance for services, and your insurance pays the rest.

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Denial

A denial is when an insurer refuses payment for a claim. Denials can occur for clinical reasons (e.g., not medically necessary), administrative reasons (e.g., incorrect coding), missing prior authorization, or coverage exclusions. Denials can often be appealed.

Go deeper: How to Write a Letter of Appeal for Claim Denials

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Denial Management Analytics

Reporting tools that identify why claims are denied and where improvements can be made, helping teams prevent repeat denials. It’s a much faster and sharper way of identifying trends in claim denials than manual data sifting.

To put it into a real world context, suppose a dermatology practice notices through analytics that 32% of its denials come from one payor due to “insufficient documentation.” The analytics report shows these denials are mostly tied to claims using a specific biopsy CPT code. With this insight, the team updates its documentation templates and trains clinicians to include required details (such as lesion size and location). The next month, denials for that code drop to 3%, recovering thousands of dollars that would have otherwise been lost.

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Denial Prevention Modeling

Predictive algorithms that flag high-risk claims before they’re submitted, allowing teams to fix issues in advance.

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Digital Fax Intake

Technology that captures, categorizes, and routes faxes from payors or providers automatically, reducing manual scanning and filing.

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Eligibility Deep-Verification

Enhanced verification that goes beyond electronic checks to uncover exclusions, plan limitations, and prior auth requirements—often via phone calls.

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Exclusive Provider Organization (EPO) Plan

An exclusive provider organization (EPO) is a managed health insurance plan where only in-network services are covered, except in emergencies.

An EPO is more restrictive than a preferred provider organization (PPO) plan. It usually has less or no coverage or reimbursement for out-of-network providers. An EPO plan typically costs less than a PPO plan.

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Excluded Service

An excluded service is a healthcare service that a health insurance plan does not cover. Examples include cosmetic procedures or experimental therapies, depending on the policy.

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Explanation of Benefits (EOB)

An Explanation of Benefits (EOB) is a statement from an insurer that explains how a claim was processed: what was billed, what the insurer paid, patient responsibility, and reasons for any denial or adjustment. 

An EOB is informational, i.e. it is not a bill, and it will often say so on the document; a separate bill from the provider is the actual request for payment.

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Family Health Insurance Plan

A family health insurance plan can be shared by spouses and any of their dependents under the age of 26.

The family pays one premium a month, and although this premium is higher than in an individual plan, a family plan usually ends up being cheaper per person than multiple individual plans.

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Good Faith Estimate

A Good Faith Estimate is an itemized estimate of expected charges for scheduled services when a patient does not use insurance (or requests one). Under U.S. law, providers must give uninsured or self-pay patients a good faith estimate of expected costs; rules about when and how to provide one vary, so providers should follow current regulations.

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Health Maintenance Organization (HMO) Plan

A health maintenance organization (HMO) is a type of health insurance plan in which coverage is limited to care from doctors who work for or contract with the HMO. HMO plans typically offer lower costs than other types of plans, but have a more restrictive provider network. HMOs provide integrated care and focus on prevention and wellness.

With an HMO, the insured must coordinate their medical care through a primary care physician (PCP). In other words, you need a referral to see a specialist.

HMO plans generally only cover out-of-network care in emergencies. An HMO may require you to live or work in its service area to be eligible for coverage. 

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Intelligent Task Routing

Automated routing systems that assign revenue cycle tasks to the right staff member—or AI agent—based on skill, urgency, and workload.

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International Classification of Diseases (ICD)

International Classification of Diseases (ICD) codes are the standard language health care professionals use to classify illnesses and diseases. They are also referred to as "diagnosis codes."

The ICD changes their list of codes every few years. The current version is ICD-10. The next edition, ICD-11 codes, are slowly being phased in, but ICD-10 is still the most current version in all 50 states. 

Go deeper: CPT and ICD-10 Coding Tips

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IVR Navigation Automation

AI systems that automatically navigate payor phone trees to reach the right department for eligibility, claims, or prior auth questions.

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Medical Necessity Validation

Tools that verify whether documented clinical details support the codes being billed, helping avoid medical necessity denials.

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Multi-Payor Data Extraction

Technology that collects benefit or claim information across many payors from calls, portals, and documents, standardizing it for RCM teams.

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National Provider Identifier (NPI)

An NPI is a unique identification number assigned to healthcare providers in the U.S. It’s used in standard electronic transactions to identify providers in administrative and billing processes.

NPI numbers were created to help send health information electronically more quickly and effectively. Covered health care providers, all health plans, and health care clearinghouses must use NPIs in their administrative and financial transactions.

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Network Exception

A network exception is a tool health insurance companies use to compensate for gaps in their network of contracted healthcare providers. It is also known as a gap exception or a network deficiency.

With a network exception, you pay in-network prices for out-of-network services. You might receive one because your network does not have a specialist you need in your area.

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No Surprises Act

The No Surprises Act (NSA) is U.S. legislation that took effect January 1, 2022. It aims to protect patients from surprise medical bills.

The NSA protects people covered under group and individual health plans from receiving surprise medical bills for the following services:

• Emergency services 
• Non-emergency services from out-of-network providers at in-network facilities
• Services from out-of-network air ambulance service providers

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Out-of-Network Reimbursement 

Out-of-network reimbursement is getting money back for out-of-network services that you have paid for. The reimbursement is paid by your insurer, after you file a reimbursement claim. 

Go deeper: The Complete Guide to Out-of-Network Reimbursement

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Out-of-Pocket Maximum

An out-of-pocket maximum is the most an insured party has to pay for covered healthcare services in a plan year. After the insured spends this amount on deductibles, copays, and coinsurance, their health plan pays 100% of the costs of covered services.

Premiums do not count toward the out-of-pocket maximum.

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Payment Acceleration Tools

Technologies that reduce payment lag by improving claim quality, automating follow-ups, and surfacing payor responses in real time.

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Payor Interaction Automation

Systems that automate communication with insurance companies—including calls, portal checks, and document requests—to reduce manual effort.

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Point of Service (POS) Plan

A POS plan combines features of HMOs and PPOs: members typically select a primary care provider and need referrals for specialists, but they have the option to go out-of-network at a higher cost.

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Preferred Provider Organization (PPO)

A PPO plan contracts with a network of preferred providers but allows members to see out-of-network providers for a higher cost. PPOs typically do not require referrals to see specialists and may have higher premiums than HMOs.

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Premium

The amount an insured party pays each month to maintain health insurance.

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Primary Care Provider (PCP)

A primary care provider (PCP) is a provider who practices general medicine and can help manage a wide variety of healthcare needs. This includes routine or preventive care like physicals, screenings and immunizations. 

They can also diagnose, treat and manage many chronic conditions and provide care when you have a minor illness or injury. They may refer you to a specialist for more in-depth care for a condition.

Common types of PCPs include:

• Internal medicine providers
• Pediatricians
• Family medicine providers
• Nurse practitioners
• Physician assistants
• Obstetrics and Gynecology (OBGYN) providers

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Prior Authorization

Prior authorization is approval a payer may require before certain services, medications, or procedures will be covered. 

Prior authorization rules vary by plan and provider; failing to obtain required authorization can lead to claim denials. Fortunately, prior auth is one of the service SuperDial’s voice AI automates for providers and medical billing companies.

It is often shortened to prior auth, or called "precertification" or "prior approval."

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Prior Authorization Rule Engine

A database or AI engine that maintains up-to-date rules on authorization requirements by payor, CPT code, and diagnosis.

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Provider

A provider is a person or organization that delivers healthcare services, such as doctors, clinics, hospitals, therapists, labs, and pharmacies.

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RCM Workflow Orchestration

A coordinated approach to managing every stage of the revenue cycle, ensuring tasks move smoothly from eligibility to reimbursement.

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Real-Time Claims Management

A modern process where claim updates, payor responses, and error flags are delivered instantly rather than in delayed batches.

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Referral

A referral is a written order, usually from a primary care provider (PCP), for a patient to see a specialist or get certain medical services.

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Specialist

A specialist is a provider who focuses on a specific area of health or a group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions.

Common types of specialists include:

• Allergists
• Cardiologists
• Chiropractors
• Dentists
• Dermatologists
• Dietitians
• Gastroenterologists
• Mental health counselors and therapists
• Neurologists
• Oncologists
• Optometrists
• Physical therapists
• Plastic surgeons
• Podiatrists

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Summary of Benefits and Coverage (SBC)

A Summary of Benefits and Coverage (SBC) is a short, plain language summary of a health insurance plan. It describes benefits and coverage of a range of services. It includes examples that show you what the plan would cover in two common medical situations: diabetes care and childbirth.

You might use this to compare plans when shopping for health insurance. All health plans must provide the SBC at important points in the enrollment process, like when you apply for or renew your policy.

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Superbill 

A superbill is a document made for insurance companies that details the services a therapist or health care provider performed for a client. 

Essentially, it’s a receipt for a trip to the doctor’s office, but unlike traditional receipts, superbills contain vital information, like diagnosis and procedure codes, needed for insurance payers to reimburse patients for the services after they’ve paid. 

They're different from regular medical bills in that insurers use them to pay patients rather than providers. Go deeper: What Is a Superbill?

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Superbill Optimization

The process of improving the structure and completeness of superbills to ensure clean coding and faster claim submission.

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Verification of Benefits (VOB)

A verification of benefits (VOB) is when a provider checks a patient's insurance to see if they have coverage for services. This is normally done before getting healthcare services to ensure it will be covered or can be reimbursed. This helps the patient know what to expect for their costs.

VOBs are a service SuperDial’s voice AI can automate for your practice or medical billing company. Go deeper: Reducing Claim Denials with AI-Powered Verification Calls.

Note: VOB and eligibility verification are often used interchangeably; “VOB” sometimes implies a more detailed check.

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Verification to Submission Pipeline

An automated workflow that moves insurance information from eligibility checks into the claim creation process seamlessly and accurately.

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