837 (Electronic Claim)
The standard electronic format used to submit healthcare claims to payers.
Plain-English definitions of the RCM, coding and billing terms that run your revenue cycle.
The standard electronic format used to submit healthcare claims to payers.
A breakdown of outstanding receivables by how long they've been unpaid (e.g., 0–30, 31–60, 61–90, 90+ days).
A formal request asking a payer to reconsider a denied or underpaid claim.
Patient balances a practice ultimately can't collect and writes off as a loss.
A standardized code on a remittance that explains why a payer adjusted or denied a claim line.
Recording the billable services a provider performed so they can be coded and billed.
Automatically checking a claim against payer and coding rules to catch errors before it's submitted.
A claim that's complete and accurate enough to be accepted and paid by the payer on the first submission, without a rejection or denial.
An intermediary that receives claims from providers, checks and formats them, and routes them to the correct payers.
The rules that determine which insurance pays first when a patient has more than one plan.
The three forms of patient cost-sharing: a flat fee per visit (copay), an amount paid before coverage kicks in (deductible), and a percentage of costs after that (coinsurance).
A standardized code that identifies the medical procedures and services a provider performed, for billing.
Verifying a provider's qualifications so they can be approved to deliver and bill for care.
The average number of days it takes to collect payment after a service is billed.
The process of categorizing, working and preventing insurance claim denials to recover revenue.
The dollar value of completed encounters that have been discharged but not yet finalized and billed - usually because they're waiting to be coded.
Confirming a patient's active insurance coverage and benefits before a visit, so claims don't bounce for inactive or changed coverage.
A statement from a payer explaining what was covered, paid, adjusted or denied on a claim.
The electronic file a payer sends that details how a claim was adjudicated - payments, adjustments and denial codes.
The list of contracted rates a payer agrees to pay a provider for each service.
The percentage of claims a payer accepts and pays on the first submission, without rework.
Total payments divided by total charges - a rough measure heavily influenced by how charges are set.
A code set used mainly for products, supplies and services not covered by CPT - such as drugs, durable medical equipment and some procedures.
A standardized diagnosis code that describes a patient's condition - the 'why' behind a billed service.
The requirement that a billed service be appropriate and necessary for the patient's diagnosis, per payer rules.
A two-character code appended to a CPT/HCPCS code to add detail - such as that a service was distinct, bilateral, or reduced.
The percentage of collectible revenue a practice actually collects, after contractual adjustments.
A unique 10-digit number that identifies a healthcare provider on claims and transactions.
The portion of a bill the patient owes - copays, deductibles and coinsurance - after insurance pays its share.
Registering a credentialed provider with a payer so their claims can be processed and paid.
Recording payer and patient payments against claims and reconciling them line by line.
Collecting the patient's expected responsibility at or before the visit, rather than billing them afterward.
A payer's requirement that a service be approved in advance before it's performed, or the claim will be denied.
A supplemental code on a remittance that adds detail to a CARC, further explaining a payment or denial.
The end-to-end financial process a healthcare practice uses to capture, manage and collect revenue for the care it delivers.
The deadline by which a claim must be submitted to a payer to be eligible for payment.
When a payer reimburses less than the contracted rate for a service.
An amount a provider removes from a patient's balance because it won't be collected - either contractually agreed or deemed uncollectible.