Comprehensive Glossary of Revenue Cycle Management (RCM) Terminology

Patient Access & Registration

Eligibility Verification: The process of confirming a patient’s insurance coverage and benefits before services are rendered.

Pre-Authorization / Prior Authorization: Approval from the insurance company required before certain procedures or services.

Patient Demographics: Basic information collected at registration (e.g., name, DOB, insurance, address).

Guarantor: The individual responsible for paying a patient’s medical bill.

ICD-10-CM: Diagnostic coding system used to classify diseases and health conditions.

CPT: Codes that describe medical, surgical, and diagnostic services.

HCPCS: Healthcare Common Procedure Coding System used for Medicare and Medicaid billing.

Medical Necessity: Services that are reasonable and necessary for the diagnosis or treatment of a condition.

Charge Capture: The process of recording services rendered for billing.

Claim Scrubbing: Reviewing claims for accuracy before submission to prevent rejections or denials.

UB-04: Claim form used for hospital billing.

CMS-1500: Standard claim form used by individual providers and group practices.

EOB (Explanation of Benefits): Summary sent by the payer explaining what was covered and what the patient owes.

ERA (Electronic Remittance Advice): Digital version of the EOB sent to providers.

Patient Responsibility: Portion of the bill not covered by insurance and owed by the patient.

Copay: Fixed amount paid by the patient at the time of service.

Coinsurance: Percentage of costs the patient must pay after meeting the deductible.

Deductible: Amount the patient must pay before insurance begins to pay.

Denial Management: Process of analyzing and appealing denied claims.

Appeal: A formal request for a payer to reconsider a denied or underpaid claim.

Reason Codes: Codes used by payers to explain claim denials or reductions.

Days in A/R: Average number of days it takes to collect payment.

Net Collection Rate: Percentage of reimbursable charges actually collected.

Gross Collection Rate: Total payments received divided by total charges billed.

Aging Report: A report showing unpaid claims categorized by the number of days outstanding.

HIPAA: Federal law protecting patient privacy and securing health information.

NPI (National Provider Identifier): Unique 10-digit identification number issued to health care providers.

OIG Exclusion List: A list of individuals and entities excluded from federally funded health programs.

EMR / EHR: Electronic systems for recording patient clinical information.

PM (Practice Management System): Software used to manage daily operations like scheduling and billing.

Clearinghouse: A third-party that checks claims for errors and forwards them to payers.

Superbill: A form used by providers detailing services rendered, used for billing.

Write-Off: Amount a provider agrees not to collect from the patient or payer.

Self-Pay: When the patient pays out-of-pocket for services.

Bad Debt: Uncollected revenue considered non-recoverable.

Fee Schedule: A provider’s set list of charges for services.