Glossary

The standard electronic claim format for professional services. 837P is the most common Zorva input. The Zorva auditor reads the encounter header (NM1*85, NM1*87, HI, DTP*472) and the service lines (LX, SV1). .edi, .837, and .txt are all accepted filename extensions.

The publicly-funded health insurance plan for Alberta residents, administered by Alberta Health. Physicians submit claims to AHCIP for the insured services they provide. Zorva is built around the AHCIP fee schedule (SOMB).

A scheduled, once-per-year comprehensive visit for an established patient. AHCIP SOMB 03.04A. Common Zorva finding: AWV billed with a same-day problem-focused visit missing modifier-25 (Zorva rule AH-MOD-25).

AHCIP GR 3.3 (CMGP Eligibility). A Comprehensive Care Management / General Practice visit (03.04A) requires a full history, full physical, and comprehensive management plan. Common Zorva finding: a focused visit was documented but a CMGP code was billed (rule AH-CG-01). The audit flags this because over-billing a CMGP is a potential fraud flag for HIA / PIPEDA purposes.

The US procedural code set maintained by the AMA. AHCIP uses the SOMB instead; CPT codes are not part of the AHCIP ruleset. Zorva's sample-format case studies use CPT to demonstrate the auditor workflow, but production AHCIP audits use SOMB fee codes and AHCIP GR references.

Office-visit codes. In AHCIP, the 03.xx series (03.03A focused, 03.04A comprehensive, 03.05A complex). In US-CPT, the 992xx series (99213 focused, 99214 moderate, 99215 complex). E/M billing is the highest-yield audit area because modifier-25, dx-linkage, and time-based coding all cluster here.

The HL7 standard for exchanging healthcare data. Zorva's upload portal accepts FHIR-formatted claims (JSON or XML) alongside 837P and CSV. FHIR is the future of EMR integration for Zorva — Accuro, TELUS PS Suite, and OSCAR Pro all support FHIR exports.

A general rule published in the AHCIP Schedule of Medical Benefits. GRs govern eligibility, documentation requirements, modifier use, and modifier-25 application. Zorva's 18 AHCIP rules cite GR 1.4 (modifier-25), GR 3.3 (CMGP), GR 4.4 (dx-linkage), GR 6.2 (referral documentation), and others.

The Alberta Health claims-submission system. Physicians and clinics submit AHCIP claims via H-Link. Zorva's audit output is the biller's review pass BEFORE the claim hits H-Link — we don't replace H-Link, we pre-flight the claim.

Alberta's health-information privacy law. Governs how custodians (clinics) and information managers (Zorva) handle personally-identifying health information. The HIA requires an Information Manager Agreement (IMA) between the custodian and the information manager before any PHI moves. Zorva's IMA template is in lawyer review (target sign-off 2026-Q3).

The US federal health-privacy law. Zorva is Alberta-first and signs HIA IMAs; HIPAA BAA templates are available for US pilots. The patient-hash design, audit-trail chain, and encryption-at-rest posture satisfy both HIA and HIPAA security rule requirements.

A scheduled preventive visit for an established patient. Like AWV, common Zorva finding: same-day problem-focused E/M billed with HMV missing modifier-25 (rule AH-MOD-25).

The HIA-required contract between a custodian (a clinic) and an information manager (Zorva). Sets out what Zorva can and can't do with the data. Zorva's IMA template is in lawyer review (target sign-off 2026-Q3). The IMA must be signed BEFORE any PHI moves to Zorva's environment.

The AI class of model that Zorva uses for the audit. Brought in by the customer — Zorva ships the prompt, the rules, the audit trail. Your data does not train anyone else's model. The MiniMax-M3 model with date-pinned snapshot is the default; OpenAI, Anthropic, Gemini, or any Ollama-compatible local endpoint is supported.

AHCIP GR 1.4. When a same-day E/M is billed alongside a procedure (e.g. office visit + joint injection, or office visit + chest X-ray), the E/M must carry modifier-25 to indicate it is a separately-identifiable service. Without modifier-25, AHCIP bundles the E/M into the procedure and pays only the procedure. Zorva's rule AH-MOD-25 is the highest-yield catch — modifier-25 gaps are the most common denial pattern in Alberta family-medicine claims.

A payer rule that caps the number of units of a procedure that can be billed in a day. Zorva flags when a claim's units exceed the MUE limit. MUE is more relevant to US-CPT claims; AHCIP uses SOMB-defined unit limits instead.

A US-based code-pair edit system. Less directly relevant to AHCIP (which has its own equivalent in the SOMB) but Zorva's NCCI coverage is wired in for US pilots.

Alberta-specific organizational structure that coordinates billing, panel management, and after-hours coverage across member clinics. ~42 PCNs province-wide. The PCN central office is often the right first call for Zorva outreach — centralized billing-quality programs at PCN scale benefit most from a pre-submit auditor.

Ontario's health-privacy law. Distinct from HIA in that PHIPA uses 'Health Information Custodian' and 'agent' terminology; HIA uses 'custodian' and 'information manager.' Zorva is Alberta-first; PHIPA templates are on request for Ontario pilots.

Canada's federal private-sector privacy law. Zorva covers PIPEDA in addition to HIA / PHIPA / HIPAA depending on jurisdiction. The patient_hash salt design follows PIPEDA's 'de-identify at the earliest practical point' requirement.

The Zorva pilot accepts 837P / CSV / paste-form. For clinics that prefer file drop, SFTP upload is available. Zorva does not require SFTP for the pilot — the contact form and the upload portal both accept direct file upload.

Alberta's billing code reference. The 18 AHCIP rules in v12 cite SOMB rule numbers and GR references. The SOMB is the source of truth for what AHCIP will and won't pay. Updated quarterly by Alberta Health; Zorva's ruleset is versioned to each SOMB release.