Answers
Terms defined
64 questions answered. The vocabulary of US revenue cycle, defined without circular definitions.
What is Accounts receivable (AR) in medical billing?
Money billed and not yet collected. In a practice it is usually reported in ageing buckets — 0-30, 31-60, 61-90, 90+ days — because the older a balance is, the less likely it is ever to be paid.
Accounts receivable (AR) definition
Money billed and not yet collected. In a practice it is usually reported in ageing buckets — 0-30, 31-60, 61-90, 90+ days — because the older a balance is, the less likely it is ever to be paid.
What is Days in AR in medical billing?
Average number of days between billing and collection. Calculated as total AR divided by average daily charges. Under 40 days is strong for most specialties; over 60 usually means nobody is calling on the aged end.
Days in AR definition
Average number of days between billing and collection. Calculated as total AR divided by average daily charges. Under 40 days is strong for most specialties; over 60 usually means nobody is calling on the aged end.
What is Clean claim rate in medical billing?
The share of claims accepted on first submission with no edit, rejection or denial. Every point below about 95% is rework somebody has to pay for.
Clean claim rate definition
The share of claims accepted on first submission with no edit, rejection or denial. Every point below about 95% is rework somebody has to pay for.
What is First pass resolution rate in medical billing?
The share of claims paid on the first submission. Different from clean claim rate, which only measures acceptance rather than payment.
First pass resolution rate definition
The share of claims paid on the first submission. Different from clean claim rate, which only measures acceptance rather than payment.
What is CARC in medical billing?
Claim Adjustment Reason Code. The standard code on a remittance explaining why a line was adjusted or denied, such as CO-197 for a missing authorization.
CARC definition
Claim Adjustment Reason Code. The standard code on a remittance explaining why a line was adjusted or denied, such as CO-197 for a missing authorization.
What is RARC in medical billing?
Remittance Advice Remark Code. The supplementary code that carries the actual detail when the CARC is generic. CO-16 without its RARC is not actionable.
RARC definition
Remittance Advice Remark Code. The supplementary code that carries the actual detail when the CARC is generic. CO-16 without its RARC is not actionable.
What is Group code in medical billing?
The two-letter prefix on a remittance line, chosen by the payer at adjudication. CO is a contractual obligation you write off and may not bill to the patient. PR is patient responsibility and is billable. OA is another adjustment, usually pointing at a…
Group code definition
The two-letter prefix on a remittance line, chosen by the payer at adjudication. CO is a contractual obligation you write off and may not bill to the patient. PR is patient responsibility and is billable. OA is another adjustment, usually pointing at a…
What is NCCI edits in medical billing?
National Correct Coding Initiative edits. CMS-published pairs of codes that should not normally be billed together, and whether a modifier is permitted to override the pair.
NCCI edits definition
National Correct Coding Initiative edits. CMS-published pairs of codes that should not normally be billed together, and whether a modifier is permitted to override the pair.
What is LCD and NCD in medical billing?
Local and National Coverage Determinations. Medicare policies stating when a service is covered. An appeal that does not quote the applicable determination usually fails.
LCD and NCD definition
Local and National Coverage Determinations. Medicare policies stating when a service is covered. An appeal that does not quote the applicable determination usually fails.
What is Prior authorization in medical billing?
Payer approval obtained before a service is delivered. Distinct from pre-certification and referral, though the words are often used interchangeably by front desks and never by payers.
Prior authorization definition
Payer approval obtained before a service is delivered. Distinct from pre-certification and referral, though the words are often used interchangeably by front desks and never by payers.
What is Retro-authorization in medical billing?
An authorization requested after the service was delivered. Many payers allow it inside a short window, sometimes as little as 72 hours, and many do not allow it at all.
Retro-authorization definition
An authorization requested after the service was delivered. Many payers allow it inside a short window, sometimes as little as 72 hours, and many do not allow it at all.
What is Eligibility verification in medical billing?
Confirming a patient’s active coverage, plan type, benefits and patient responsibility before the visit. The cheapest denial prevention available.
Eligibility verification definition
Confirming a patient’s active coverage, plan type, benefits and patient responsibility before the visit. The cheapest denial prevention available.
What is Coordination of benefits (COB) in medical billing?
The rules deciding which payer is primary when a patient has more than one plan. A stale COB record on the payer’s file will stop every claim until it is corrected.
Coordination of benefits (COB) definition
The rules deciding which payer is primary when a patient has more than one plan. A stale COB record on the payer’s file will stop every claim until it is corrected.
What is Timely filing limit in medical billing?
The deadline for submitting a claim, set by contract. Ranges from 90 days to 365 depending on the payer, and missing it is usually terminal.
Timely filing limit definition
The deadline for submitting a claim, set by contract. Ranges from 90 days to 365 depending on the payer, and missing it is usually terminal.
What is Credentialing in medical billing?
Verifying a provider’s qualifications so they can be enrolled with a payer. Distinct from enrollment, though the two are done together and usually spoken of as one thing.
Credentialing definition
Verifying a provider’s qualifications so they can be enrolled with a payer. Distinct from enrollment, though the two are done together and usually spoken of as one thing.
What is Revalidation in medical billing?
Periodic re-verification of an existing enrollment. Missing a revalidation deadline can suspend payment on every claim behind it, which makes it the most expensive administrative deadline in a practice.
Revalidation definition
Periodic re-verification of an existing enrollment. Missing a revalidation deadline can suspend payment on every claim behind it, which makes it the most expensive administrative deadline in a practice.
What is CAQH in medical billing?
The shared credentialing database most commercial payers pull from. If a CAQH profile goes stale or unattested, enrollments start failing quietly.
CAQH definition
The shared credentialing database most commercial payers pull from. If a CAQH profile goes stale or unattested, enrollments start failing quietly.
What is PECOS in medical billing?
Medicare’s provider enrollment system. Enrollment status and effective dates live here, and the effective date is what determines which claims are recoverable after a lapse.
PECOS definition
Medicare’s provider enrollment system. Enrollment status and effective dates live here, and the effective date is what determines which claims are recoverable after a lapse.
What is Charge entry in medical billing?
Getting the services performed into the billing system as billable lines. Errors introduced here are cheap to fix and expensive to find later.
Charge entry definition
Getting the services performed into the billing system as billable lines. Errors introduced here are cheap to fix and expensive to find later.
What is Write-off in medical billing?
A balance removed from AR without collection. Contractual write-offs are expected; everything else is a loss that should be counted and explained.
Write-off definition
A balance removed from AR without collection. Contractual write-offs are expected; everything else is a loss that should be counted and explained.
What is Underpayment in medical billing?
A claim paid at less than the contracted rate. Hides easily inside routine CO-45 adjustments because the code looks normal.
Underpayment definition
A claim paid at less than the contracted rate. Hides easily inside routine CO-45 adjustments because the code looks normal.
What is Davis-Bacon Act in medical billing?
The federal law requiring prevailing wages on federally funded construction contracts, and with it weekly certified payroll reporting.
Davis-Bacon Act definition
The federal law requiring prevailing wages on federally funded construction contracts, and with it weekly certified payroll reporting.
What is Prevailing wage in medical billing?
The wage and fringe benefit rate that must be paid for a given classification on a public works job in a given locality, set by a wage determination.
Prevailing wage definition
The wage and fringe benefit rate that must be paid for a given classification on a public works job in a given locality, set by a wage determination.
What is Certified payroll in medical billing?
The weekly payroll report a public works contractor must file, listing each worker, classification, hours, rate and fringe benefits, signed under a statement of compliance.
Certified payroll definition
The weekly payroll report a public works contractor must file, listing each worker, classification, hours, rate and fringe benefits, signed under a statement of compliance.
What is WH-347 in medical billing?
The US Department of Labor form used for federal certified payroll. Most states run their own portal in addition to it.
WH-347 definition
The US Department of Labor form used for federal certified payroll. Most states run their own portal in addition to it.
What is Wage determination in medical billing?
The published schedule of prevailing wage rates by classification and locality that applies to a specific public works contract.
Wage determination definition
The published schedule of prevailing wage rates by classification and locality that applies to a specific public works contract.
What is Fringe benefits in medical billing?
The benefit portion of a prevailing wage obligation. It can be paid as bona fide benefits or as cash in lieu, and calculating it wrongly gets a certified payroll rejected or turns into a back-wage finding.
Fringe benefits definition
The benefit portion of a prevailing wage obligation. It can be paid as bona fide benefits or as cash in lieu, and calculating it wrongly gets a certified payroll rejected or turns into a back-wage finding.
What is Statement of compliance in medical billing?
The signed declaration on a certified payroll filing that the payroll is correct and that prevailing wages were paid. It carries personal legal weight, which is why the contractor signs and not the vendor.
Statement of compliance definition
The signed declaration on a certified payroll filing that the payroll is correct and that prevailing wages were paid. It carries personal legal weight, which is why the contractor signs and not the vendor.
What is Revenue cycle management (RCM) in medical billing?
The full financial process around a patient encounter, from scheduling, eligibility and authorization before the visit, through coding and claim submission, to payment posting, denial management and AR follow-up after. Medical billing is one stage inside it,…
Revenue cycle management (RCM) definition
The full financial process around a patient encounter, from scheduling, eligibility and authorization before the visit, through coding and claim submission, to payment posting, denial management and AR follow-up after. Medical billing is one stage inside it,…
What is Denial management in medical billing?
The ongoing work of identifying why a claim was denied, correcting or appealing it, and tracking the pattern across denials so the same preventable reason stops recurring. Reactive on a single claim, preventive at the practice level.
Denial management definition
The ongoing work of identifying why a claim was denied, correcting or appealing it, and tracking the pattern across denials so the same preventable reason stops recurring. Reactive on a single claim, preventive at the practice level.
What is Payment posting in medical billing?
Recording what a payer actually paid against each claim line, including the adjustment, deductible, coinsurance and copay shown on the remittance, so the patient account reflects the real balance.
Payment posting definition
Recording what a payer actually paid against each claim line, including the adjustment, deductible, coinsurance and copay shown on the remittance, so the patient account reflects the real balance.
What is Billing company in medical billing?
A vendor that performs some or all of a practice’s revenue cycle on its behalf. The title covers a wide range of actual scope, from claims and AR only to a full end-to-end service, so what is included has to be confirmed rather than assumed.
Billing company definition
A vendor that performs some or all of a practice’s revenue cycle on its behalf. The title covers a wide range of actual scope, from claims and AR only to a full end-to-end service, so what is included has to be confirmed rather than assumed.
Other answer sets
- Eligibility and coverage denials
- Coding and documentation denials
- AR and appeals denials
- Enrollment and credentialing denials
- Prior authorization denials
- Charge entry, posting and patient balance denials
- Specialty billing
- Practice management and EHR systems
- Prompt pay deadlines
- By state
- Services and pricing
- About Soft Home Global
Next step
Somebody who does this every day
Twenty minutes on a call answers more than any reference page. Prices are published, so there is nothing to extract from you first.
Or write to ops@softhomeglobal.com