Healthcare RCM glossary
Plain-English definitions of 80 revenue cycle, dental billing, medical billing, and automation terms, written for billing and RCM teams.
A
- Accounts Receivable (AR)Core RCMAccounts Receivable (AR) represents the outstanding balance of money owed to a healthcare practice for services already…
- Accounts Receivable Aging ReportCore RCMAccounts Receivable Aging Report is a core RCM report that categorizes unpaid patient and payer balances by how long…
- Agentic AITechnologyAgentic AI refers to artificial intelligence systems designed to operate with a high degree of autonomy, making…
- AI AgentsTechnologyAI agents are autonomous software systems that use artificial intelligence to perceive their environment, make…
- Allowed AmountCore RCMAllowed Amount refers to the maximum a payer will reimburse for a covered service under a contract or fee schedule. It…
- Ambient AI (Healthcare)TechnologyAmbient AI (Healthcare) refers to always-on AI that observes clinical and administrative workflows to capture context…
- Appeal Success RateCore RCMAppeal Success Rate is the percentage of denied claims that are overturned and paid after an appeal. It is typically…
- AR Days (Days in Accounts Receivable)Core RCMAR Days measures the average number of days it takes a healthcare organization to collect payment after a service is…
B
- Bad DebtCore RCMBad Debt refers to patient or payer balances deemed uncollectible after reasonable internal and external collection…
- Balance BillingCore RCMBalance Billing refers to charging a patient the difference between a provider’s billed charge and the payer’s allowed…
- Batch Claims ProcessingTechnologyBatch Claims Processing refers to submitting, validating, status-checking, and reconciling large groups of claims in…
- Benefit BreakdownDentalA benefit breakdown is a detailed summary of a patient's dental insurance coverage, including annual maximums,…
- Browser-Native AutomationTechnologyBrowser-native automation is a technology approach that interacts with applications through the user interface,…
C
- CDT CodesDentalCDT Codes refers to the American Dental Association’s Current Dental Terminology code set used to describe dental…
- Charge CaptureCore RCMCharge Capture is the process of accurately recording all billable services, procedures, and supplies provided to a…
- Charge Master (CDM)Core RCMCharge Master (CDM) is the centralized catalog of billable services, supplies, codes (e.g., CPT/HCPCS, revenue codes),…
- Claim AdjudicationCore RCMClaim Adjudication is the payer’s process of evaluating a submitted claim against eligibility, coverage, coding edits,…
- Claim DenialCore RCMA claim denial occurs when an insurance payer refuses to honor a submitted claim for payment, either in whole or in…
- Claim ScrubbingCore RCMClaim scrubbing is the process of reviewing and validating insurance claims for errors, omissions, and payer-specific…
- Clean ClaimCore RCMA clean claim is a submitted insurance claim that contains all required data elements, is free of errors, and can be…
- Clean Claim RateCore RCMClean Claim Rate is the percentage of claims accepted and adjudicated by payers without front-end rejection, manual…
- Clinical Documentation Improvement (CDI)MedicalClinical Documentation Improvement (CDI) is a discipline that ensures provider documentation accurately reflects the…
- Computer Vision in HealthcareTechnologyComputer Vision in Healthcare refers to algorithms that interpret images, documents, and on-screen elements to automate…
- Contracted RateCore RCMContracted Rate is the negotiated in-network allowed amount a payer agrees to reimburse a provider for a specific…
- Coordination of Benefits (COB)Core RCMCoordination of Benefits (COB) is the process of determining which insurance plan pays first (primary) and which pays…
- CPT Codes (Current Procedural Terminology)MedicalCPT codes are a standardized medical code set maintained by the American Medical Association (AMA) used to describe…
- CredentialingMedicalCredentialing is the process of verifying a healthcare provider's qualifications, including education, training,…
D
- Days Sales Outstanding (DSO)Core RCMDays Sales Outstanding (DSO) measures the average number of days it takes to collect revenue after a sale or service has…
- Denial RateCore RCMDenial Rate is the percentage of claims rejected or denied by payers during adjudication, typically measured on first…
- Dental Claim AttachmentDentalA dental claim attachment is supplementary documentation (such as X-rays, periodontal charting, narratives, or intraoral…
- Dental Claim Attachment (NEA)DentalDental Claim Attachment (NEA) refers to electronic supporting documentation—such as X-rays, perio charting, intraoral…
- Dental PPO vs. DHMODentalDental PPO vs. DHMO refers to the two dominant dental plan designs and how they reimburse providers and guide patient…
- Dental Pre-AuthorizationDentalDental pre-authorization (also called pre-determination or pre-treatment estimate) is the process of submitting a…
- Dental PredeterminationDentalDental Predetermination refers to submitting a proposed treatment plan to a dental payer for a pre-treatment estimate of…
- Dental RCM AutomationDentalDental RCM automation refers to the use of technology to streamline and automate revenue cycle management processes…
- DSO (Dental Support Organization)DentalA Dental Support Organization (DSO) is a management company that provides non-clinical business support services to…
E
- Electronic Remittance Advice (ERA)Core RCMElectronic Remittance Advice (ERA) is the ANSI X12 835 transaction that details how a payer adjudicated claims,…
- Eligibility VerificationCore RCMEligibility verification is the process of confirming a patient's active insurance coverage, benefits, and plan details…
- ERA/EOB (Electronic Remittance Advice / Explanation of Benefits)Core RCMAn Electronic Remittance Advice (ERA) is the electronic version of an Explanation of Benefits (EOB) sent from a payer to…
- Explanation of Benefits (EOB)MedicalAn Explanation of Benefits (EOB) is a document sent by an insurance payer to both the provider and the patient that…
F
- Fee ScheduleCore RCMFee Schedule refers to the payer- or provider-defined list of allowed reimbursement amounts for specific procedure codes…
- First-Pass Resolution RateCore RCMFirst-pass resolution rate (also called first-pass yield or first-pass acceptance rate) measures the percentage of…
- Frequency Limitations (Dental)DentalFrequency Limitations (Dental) refers to plan rules that restrict how often specific CDT-coded services are covered…
H
- Healthcare ClearinghouseCore RCMHealthcare Clearinghouse refers to a HIPAA-defined intermediary that translates, edits, and routes healthcare…
- HIPAA ComplianceTechnologyHIPAA (Health Insurance Portability and Accountability Act) compliance refers to adherence to federal regulations that…
- Human-in-the-Loop AITechnologyHuman-in-the-Loop AI refers to AI-driven workflows that keep trained staff in control of approvals, exceptions, and…
I
- ICD-10 (International Classification of Diseases, 10th Revision)MedicalICD-10 is the international standard diagnostic classification system used to code and classify diseases, symptoms,…
- Insurance Verification (Dental)DentalDental insurance verification is the process of confirming a patient's dental coverage details, including plan type,…
- Intelligent Document Processing (IDP)TechnologyIntelligent Document Processing (IDP) is the use of AI (OCR, NLP, and computer vision) to classify, extract, and…
M
- Maximum Allowable BenefitDentalMaximum Allowable Benefit is the total dollar cap a dental insurance plan will pay for covered services within a benefit…
- Medical Billing vs. Medical CodingMedicalMedical Billing vs. Medical Coding refers to two connected but distinct functions in the revenue cycle. Coding…
- Medical NecessityMedicalMedical necessity is the standard used by insurance payers to determine whether a healthcare service, procedure, or…
- Modifier (CPT Modifier)MedicalModifier (CPT Modifier) is a two-digit numeric suffix appended to a CPT code to indicate that a service or procedure has…
N
- Narrative Report (Dental Claims)DentalNarrative Report (Dental Claims) refers to the concise clinical summary included with a claim or attachment that…
- National Provider Identifier (NPI)MedicalNational Provider Identifier (NPI) is a unique 10-digit identifier assigned by CMS through NPPES to healthcare providers…
- Net Collection RateCore RCMNet collection rate measures the percentage of allowable charges that a healthcare organization actually collects. It is…
P
- Patient AccessCore RCMPatient Access refers to the front-end processes that connect patients to care and financially clear them, including…
- Patient ResponsibilityCore RCMPatient Responsibility is the portion of a healthcare bill the patient owes after payer adjudication, including…
- Payer Intelligence LayerTechnologyA payer intelligence layer is a system that aggregates and normalizes data from many insurance payers — benefits, claim…
- Payer MixCore RCMPayer Mix is the distribution of an organization’s patient volume or net revenue across payer categories such as…
- Payer PortalDentalA payer portal is a web-based platform provided by an insurance company where healthcare providers can perform…
- Place of Service CodeMedicalPlace of Service Code refers to the two-digit CMS code set that indicates where a patient received services on a…
- Preauthorization vs. PredeterminationCore RCMPreauthorization vs. Predetermination refers to two different payer processes used before care is delivered.…
- Prior AuthorizationCore RCMPrior authorization (also called pre-authorization or pre-cert) is the process of obtaining approval from an insurance…
R
- RCM Key Performance Indicators (KPIs)Core RCMRCM Key Performance Indicators (KPIs) refers to the measurable metrics used to assess the financial and operational…
- Real-Time AdjudicationTechnologyReal-Time Adjudication is the immediate processing of a submitted claim by a payer, returning an adjudication…
- Remittance AdviceMedicalRemittance advice is a document accompanying a payment from an insurance payer that provides a detailed breakdown of how…
- Revenue Cycle AutomationTechnologyRevenue cycle automation is the application of technology to streamline, optimize, and execute healthcare billing and…
- Revenue Cycle Management (RCM)Core RCMRevenue Cycle Management (RCM) encompasses all administrative and clinical functions that contribute to the capture,…
- Revenue IntegrityMedicalRevenue Integrity refers to the end-to-end controls that ensure charges, coding, billing, and reimbursement accurately…
- RPA (Robotic Process Automation)TechnologyRobotic Process Automation (RPA) is a technology that uses software robots (bots) to automate repetitive, rule-based…
S
- Self-PayCore RCMSelf-Pay refers to amounts a patient owes directly, either because they are uninsured or because insurance left a…
- SOC 2 ComplianceTechnologySOC 2 (Service Organization Control 2) is an auditing framework developed by the AICPA that evaluates an organization's…
- SuperbillCore RCMSuperbill refers to an itemized encounter document that captures services rendered, diagnosis and procedure codes,…
U
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