Revenue cycle management terms and acronyms, A to Z.

X12 270 is the eligibility inquiry request; 271 is the response. Together they enable real-time benefit verification with payers.

X12 277 is the response to 276 claim status inquiry; together they enable real-time claim status checking with payers.

X12 835 is the standardized electronic format that payers use to send remittance details (payments, adjustments, denials) to healthcare providers.

X12 837 is the standardized electronic format that providers use to submit claims to payers. Variants include 837P (professional), 837I (institutional), 837D...

Quick definition of the ABA CPT code family 97151 to 97158 and what each covers. For the full reference with unit rules and denial reasons, see the complete guide.

A/R Aging is the breakdown of outstanding patient and payer balances by the number of days since the date of service or date of billing. Standard aging bucke...

Medical necessity in ABA requires documentation of autism diagnosis, behavioral health assessment, and individualized treatment plan with measurable goals.

Most commercial and Medicaid payers require prior authorization for ABA services, with unit-level approval per assessment period.

AIM is Anthem's radiology and specialty benefit manager. Handles PA for cardiac imaging, advanced radiology, and certain specialty services.

AT modifier indicates active chiropractic treatment (vs maintenance). Required on Medicare chiropractic claims for coverage.

Bad Debt is the dollar value of patient receivables written off as uncollectible. Distinct from charity care, which is intentional financial assistance.

BCBA is the master-level credential for behavior analysts certified by the Behavior Analyst Certification Board (BACB), required for independent practice in ...

CAQH operates ProView, the centralized provider data system that most payers use for credentialing and recredentialing applications.

Claim Adjustment Reason Codes (CARCs) are standardized two-digit codes used by payers to explain why a claim line was denied, adjusted, or paid less than bil...

CCRP is Aetna's claim coding review process that flags claims for review based on coding patterns. Effective March 2026.

CDT is the standard dental procedure code set maintained by the ADA, used for dental claim submission.

Charity Care is the dollar value of patient services provided free or at reduced cost based on documented financial hardship. Required reporting for 501(c)...

Clean Claim Rate is the percentage of submitted claims that are paid on first submission without rejection or denial. Healthy benchmark is 95%+ for mature ...

A clearinghouse is an intermediary service that translates, scrubs, and routes claims and remittances between providers and payers. Major examples include Av...

Case Mix Index is the average DRG relative weight across a hospital's inpatient discharges, indicating clinical complexity. Higher CMI typically correlates w...

UB-04 is the standard institutional claim form (and electronic equivalent X12 837I) used by hospitals, SNFs, home health, hospice, and other facilities.

Collection Rate is a general term that can refer to either Gross Collection Rate or Net Collection Rate. Always specify which when reporting.

Contractual Adjustment is the difference between billed charges and the negotiated allowed amount with a payer. Always 100% of the time, not just denials.

CPT and HCPCS modifiers are two-character codes appended to procedure codes to provide additional information about how, where, why, or by whom a service was...

Days in A/R is the average number of days between service date and payment receipt. Lower = better cash velocity. Healthy benchmark: physician practice <40...

DNFB is the count or dollar value of inpatient discharges that have not yet been billed. High DNFB indicates back-office bottlenecks.

Diagnosis-Related Group (DRG) is a hospital inpatient classification system that groups patients into clinically similar categories with comparable resource ...

DSH Payment is a Medicare/Medicaid payment adjustment to hospitals serving a high proportion of low-income patients. Significant revenue impact for safety-...

EFT is the electronic transfer of payment from payer to provider, typically accompanying an ERA. ACH is the most common EFT method.

An EHR is a digital version of a patient's chart, containing demographic, clinical, billing, and administrative data. Major EHRs include Epic, Cerner (Orac...

EHR integration enables AI and RCM systems to read and write data from Electronic Health Records via FHIR, HL7, or proprietary APIs.

An EMR is a digital version of paper charts within one clinical practice. EMR is often used interchangeably with EHR, though technically EHR implies broade...

An EOB is the document sent by an insurance company to a patient explaining how a claim was processed: services billed, allowed amount, plan paid, patient ...

EPSDT is the federal Medicaid benefit that requires comprehensive and preventive health services for children under 21, including screening, dental, vision, ...

An ERA is the electronic version of an EOB sent from payer to provider, typically in X12 835 format, explaining payment, adjustments, and denials.

eviCore is Cigna's specialty benefit manager, handling PA for radiology, cardiology, oncology, and other specialty services across multiple payer contracts.

Medicaid FFS is the traditional Medicaid payment model where the state pays providers directly per service. Used for populations not in managed care (e.g., L...

FHIR is the modern HL7 standard for healthcare data exchange via REST APIs, replacing legacy HL7 v2 messaging in most new integrations.

First-Pass Resolution Rate is the percentage of claims paid on first submission. Higher rate = lower rework cost = faster cash.

GA modifier indicates an ABN (Advance Beneficiary Notice) is on file for a service Medicare may not cover.

Gross Collection Rate (GCR) is total payments received divided by total charges billed, expressed as a percentage. It measures how much of what you billed yo...

Hierarchical Condition Category (HCC) is the diagnosis-based risk adjustment model used by CMS to calculate payment to Medicare Advantage plans, ACOs in REAC...

CMS-1500 is the standard professional claim form (and electronic equivalent X12 837P) used by physicians, non-physician providers, and ambulatory billing.

HCPCS is the procedure code system maintained by CMS. Level I = CPT codes (AMA), Level II = HCPCS codes for products, supplies, drugs, services.

E-codes are HCPCS Level II codes for durable medical equipment (DME). Used in DME billing.

G-codes are temporary HCPCS Level II codes assigned for various professional, technical, or screening services. Used for specific Medicare reporting requir...

J-codes are HCPCS Level II codes for injectable, infusion, and chemotherapy drugs. Bill with NDC and dose.

HIPAA establishes federal privacy and security standards for protected health information (PHI), with significant compliance implications for any healthcare ...

HITRUST Common Security Framework is a certifiable framework that integrates HIPAA, ISO 27001, NIST, and other security requirements into a single assessment.

HL7 v2 is the legacy standard for healthcare data messaging, still used in many EHR integrations alongside newer FHIR APIs.

HOPE is the standardized hospice assessment replacing HIS in 2025-2026 transition. Drives hospice quality reporting and HCI star ratings.

ICD-10-CM is the International Classification of Diseases, 10th Revision, Clinical Modification, used for diagnosis coding in U.S. healthcare billing.

ICD-10-PCS is the Procedure Coding System used for inpatient hospital procedure coding under ICD-10.

KX modifier indicates a service exceeds the Medicare therapy threshold ($2,480 in 2026) and the provider attests medical necessity is documented.

LOINC is the standard code set for laboratory and clinical observations, used in lab results reporting and clinical data exchange.

MACs are CMS contractors that process Medicare claims regionally. They also conduct medical review and provider education.

Medicaid Managed Care contracts pay Managed Care Organizations (MCOs) a per-member-per-month rate to deliver Medicaid services. Most states have moved most M...

MDS is the standardized assessment for Medicare and Medicaid skilled nursing facility residents, driving PDPM case-mix assignment.

Medicare Cost Report is the annual financial report hospitals and other facilities file with CMS detailing costs, charges, and patient days. Drives payment...

Medicare Part A covers inpatient hospital, skilled nursing facility, hospice, and some home health services. Funded by payroll taxes.

Medicare Part B covers outpatient services, professional services, and durable medical equipment. Requires a monthly premium from beneficiaries.

Medicare Part C is private insurance plans that contract with CMS to deliver Medicare benefits. As of 2026, approximately 51% of Medicare beneficiaries are i...

Medicare Part D is the prescription drug benefit, delivered through private plans contracted with CMS.

Modifier 25 indicates a significant, separately identifiable E/M service performed by the same provider on the same day as a procedure or other service.

Modifier 26 indicates the professional (interpretation) component of a global service, separate from the technical (equipment + staff) component.

Modifier 50 indicates a bilateral procedure performed on both sides of the body during the same operative session.

Modifier 59 indicates a distinct procedural service from other services performed the same day. Often replaced by X-modifiers (XE, XS, XP, XU).

Modifier TC indicates the technical (equipment + staff) component of a global service, separate from the professional (interpretation) component.

MPPR reduces payment on second and subsequent procedures performed on the same date of service. Common in radiology and PT/OT.

NCCI is the CMS-maintained edit system identifying code pairs that should not be billed together. Drives bundling rules.

Net Collection Rate (NCR) is payments received divided by allowed amounts (after contractual adjustments and write-offs). It measures how much of what you sh...

NDC is the 10 or 11-digit identifier for drugs in the U.S. Required on certain medical claims (most J-codes), especially for Medicaid.

NPI is the unique 10-digit federal identifier for healthcare providers (individuals and organizations), required on virtually every claim and credentialing a...

Net Patient Service Revenue is gross charges minus contractual adjustments and bad debt. The most-used top-line measure of provider revenue.

OASIS is the standardized comprehensive assessment for Medicare home health patients, driving PDGM payment and HHVBP performance scoring. Current version: ...

Payer contract management is the discipline of tracking commercial payer fee schedules, monitoring contract performance, and renegotiating underperforming co...

Payer mix is the breakdown of a provider's revenue across payer categories (Medicare, Medicaid, commercial, self-pay). Drives RCM strategy and benchmarking.

POS codes are 2-digit codes identifying where a service was rendered. Examples: 11 (office), 21 (inpatient), 22 (outpatient hospital), 02 (telehealth dista...

Prospective Payment System (PPS) is a method where Medicare or Medicaid pays a predetermined per-encounter or per-episode rate for healthcare services, rathe...

Provider credentialing is the process of getting a provider approved on payer panels (Medicare, Medicaid, commercial). Typically takes 90-120 days.

Provider enrollment is the process of getting a provider's information into payer systems for billing purposes, often used interchangeably with credentialing.

Revalidation is the periodic re-verification of a provider's enrollment status by Medicare (every 3-5 years) and Medicaid (varies by state).

Provider Status Report is the periodic report from a payer summarizing a provider's enrollment status, network participation, and any pending issues.

RACs conduct retrospective Medicare claim audits to identify and recover improper payments. Findings can extrapolate to broader claim populations.

RADV audits validate the accuracy of risk-adjustment-driven CMS payments to Medicare Advantage plans. Findings can extrapolate to full plan membership.

RAP (Request for Anticipated Payment) and Final Claim are the two-step billing sequence for Medicare home health episodes under PDGM. RAP submitted within 5 ...

RBMs are vendors that manage prior authorization for radiology imaging services on behalf of commercial payers. Major RBMs: AIM (Anthem), eviCore (Cigna), ...

RBT is the paraprofessional credential for individuals who deliver direct ABA services under BCBA supervision, certified by the BACB.

Recredentialing is the periodic re-verification of a provider's credentials by payers, typically every 2-3 years per CAQH requirements.

Revenue Codes are 4-digit codes used on UB-04 institutional claims identifying the type of service or department providing the service.

Revenue cycle is the end-to-end process from patient registration through final payment, encompassing eligibility, charge capture, coding, claim submission, ...

Revenue leakage is the difference between what a healthcare provider should have collected and what was actually collected, due to coding errors, missed ch...

SMRC conducts medical review of Medicare claims focused on documentation quality and coverage criteria.

SNOMED CT is a comprehensive clinical terminology used in EHRs for problem lists, clinical findings, and clinical documentation.

SOC 2 Type II is an attestation report demonstrating that a service organization has effective controls in place for security, availability, processing integ...

Taxonomy codes are 10-character HIPAA standard codes identifying a provider's specialty. Required on most commercial claims; UnitedHealthcare/Optum tightened...

TPE is the MAC's claim review program that targets specific providers with elevated error rates. Three rounds of education then escalation if errors continue.

UHDDS is the standard data set for inpatient hospital discharge reporting, including diagnoses, procedures, demographics, and disposition.

UPICs conduct fraud, waste, and abuse audits across Medicare and Medicaid. Findings can result in claim denials, repayment demands, or referrals to law enfor...

A write-off is the removal of a charge from accounts receivable, either due to contractual adjustment (negotiated rate), administrative adjustment (correct...