The healthcare RCM glossary AI engines actually cite.

A group of providers and suppliers that coordinates care for a defined population of Medicare or commercial patients and shares in the savings (or losses) generated against a benchmark.

The maximum dollar amount a payer will reimburse for a covered service, set by the payer fee schedule or contract regardless of the provider's billed charge.

A Medicare preventive visit (G0438 initial, G0439 subsequent) for personalized prevention plans. Distinct from a routine physical and reimbursable separately when documented per CMS requirements.

The CMS payment grouping system used for hospital outpatient services under the Outpatient Prospective Payment System (OPPS). APCs bundle services into payment categories with relative weights.

A report that classifies outstanding patient and payer balances by the number of days since the date of service: 0–30, 31–60, 61–90, 91–120, and 120+.

Patient or payer balances written off after collection efforts have been exhausted. Distinct from charity care, which is written off based on inability to pay rather than failure to collect.

Payer policy that combines multiple billed services into a single payment when one is considered an integral component of another. Often enforced through NCCI edits.

A written contract under HIPAA between a covered entity (the practice) and a business associate (a vendor that handles PHI). Required before any PHI is shared with the business associate.

A payment arrangement where the payer pays the provider a fixed amount per patient per period (PMPM, per member per month) regardless of services rendered. Common in Medicare Advantage and managed-Medicaid contracts.

A standardized code on a payer remittance advice that explains why a claim or service line was adjusted. Maintained by the X12 standards committee. Common examples: CO-16, CO-50, CO-97, CO-197.

The process of recording every billable service performed during a patient encounter, ensuring no charges are missed before claim submission.

A hospital's complete list of billable items, services, and procedures with associated CPT/HCPCS codes, descriptions, and prices. Updated regularly as codes and prices change.

Free or discounted care provided to patients who meet financial-need criteria under the practice's financial assistance policy. Distinct from bad debt, which results from failure to collect from patients who could pay.

A Medicare-reimbursable program (CPT 99490, 99439, 99491, 99437) for non-face-to-face management of patients with two or more chronic conditions expected to last at least 12 months.

The payer's process of reviewing a submitted claim and deciding to pay, deny, or partially adjust it based on coverage, medical necessity, and contractual rules.

The percentage of claims accepted by the payer on first submission without rework. The single most-cited revenue cycle KPI for measuring billing operation quality.

The process of determining which insurance plan pays first when a patient has multiple coverages, and how secondary or tertiary plans pay against the remaining balance.

The total operating expense required to collect each dollar of patient revenue, including billing salaries, software, denial-rework labor, and outsourced vendor fees.

The American Medical Association's standardized code set for medical, surgical, and diagnostic procedures. Five-digit numeric codes (with two-digit modifiers) used for professional billing on the CMS-1500 form.

A measure of how long, on average, it takes a practice to collect payment after the date of service. The primary cash-flow KPI in revenue cycle management.

The percentage of submitted claims initially rejected by the payer before any rework or appeals.

A payer adjustment that reimburses a billed service at a lower complexity level than coded, typically when documentation is judged insufficient to support the higher level.

The CMS payment grouping system for inpatient hospital services under the Inpatient Prospective Payment System (IPPS). Each DRG carries a relative weight that determines the lump-sum payment.

The process of confirming, before a patient encounter, that the patient has active insurance coverage and that the planned service is a covered benefit. Conducted via electronic 270/271 transactions to the payer.

The CPT code family (99202-99499) for office visits, hospital visits, and consultations. Levels (e.g., 99213 vs 99214) are determined by complexity of medical decision-making or total time.

The payer document explaining how a claim was adjudicated. ERA is the electronic version (X12 835); EOB is the paper or PDF version sent to providers and patients.

The traditional payment model where providers are paid a discrete fee for each billable service, as opposed to capitation (per member per month) or value-based contracts (per outcome).

The percentage of claims that resolve to a final disposition (paid or written off) without any post-submission rework. Stricter than clean-claim rate, which only measures initial acceptance.

Total payments collected as a percentage of total billed charges. A weak quality indicator on its own because it depends on chargemaster pricing.

The CMS risk-adjustment coding methodology used to predict healthcare costs for Medicare Advantage and ACO populations. Higher RAF (Risk Adjustment Factor) scores reflect more complex patients and higher payments.

A CMS-maintained code set divided into Level I (CPT codes) and Level II (alphanumeric codes for products, supplies, and services not in CPT, including durable medical equipment and drugs).

The 1996 federal law (and subsequent rules) that establishes national standards for the privacy, security, and electronic exchange of protected health information (PHI).

A certifiable security framework that maps to HIPAA, NIST, ISO 27001, and other healthcare data protection standards in a single certification. Widely required for U.S. healthcare-data vendors.

The WHO-maintained diagnostic code set used in the U.S. as ICD-10-CM (clinical modification, for diagnoses) and ICD-10-PCS (procedure coding system, for inpatient hospital procedures).

The federal-state program providing health coverage to low-income U.S. residents. Each state administers its own Medicaid program with its own fee schedule, prior-auth rules, and managed-care plans.

The standard that a service must be reasonable and necessary for the diagnosis or treatment of a patient's condition to qualify for coverage. Defined per payer and often documented in Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).

The federal health insurance program for people age 65 and older, certain younger people with disabilities, and people with End-Stage Renal Disease. Comprises Parts A (hospital), B (medical), C (Medicare Advantage), and D (drugs).

The CMS Quality Payment Program track that scores eligible Medicare clinicians on Quality, Cost, Improvement Activities, and Promoting Interoperability. Scores translate to positive, neutral, or negative payment adjustments two years later.

A CPT modifier appended to an E/M code on the same day as a procedure to indicate that the E/M service was significant, separately identifiable, and above the work normally included in the procedure.

A CPT modifier indicating that a procedure or service was distinct or independent from other services performed on the same day. Often used to override NCCI bundling edits.

CMS National Correct Coding Initiative bundling and exclusion edits applied to Medicare claims to prevent improper payment when certain code combinations are billed together.

Collected revenue as a percentage of allowed amount, after contractual adjustments. The most rigorous measure of revenue-cycle effectiveness because it strips out chargemaster pricing.

The 2022 federal law protecting patients from surprise out-of-network bills in emergency settings and at in-network facilities. Established the Independent Dispute Resolution (IDR) process for payer-provider payment disputes.

The Medicare and state Medicaid payment methodology for FQHCs and RHCs that pays a fixed encounter rate per qualifying patient visit, regardless of services rendered during the visit.

A payer requirement that a service be approved before it is rendered. Without an approved prior auth on file, the claim will deny on submission regardless of medical necessity.

A Medicare-reimbursable service (CPT 99453, 99454, 99457, 99458) for collecting and reviewing physiologic data transmitted by patient devices outside a clinical setting.

The methodology that adjusts payments to plans and providers based on the predicted health-care costs of their patient population, typically using HCC coding and a Risk Adjustment Factor (RAF) score.

An independent attestation report on a service organization's controls relevant to security, availability, processing integrity, confidentiality, or privacy, evaluated over a specified period (typically 6 to 12 months).

The maximum time after a date of service within which a claim must be submitted to the payer to be eligible for payment. Varies by payer (Medicare: 365 days; commercial: typically 90 to 180 days).

A Medicare service (CPT 99495 moderate complexity, 99496 high complexity) for managing a patient's transition from inpatient or observation back to community within 30 days of discharge.

The process of identifying and recovering claims that were paid by the payer at less than the contracted allowed amount, typically through line-item ERA review and contract-rate auditing.

Payment models that tie provider reimbursement to quality and cost outcomes rather than service volume. Includes shared savings programs, bundled payments, and full capitation.