AMBA CMRS cheat sheet

Registration data elements that drive reimbursement: legal name, DOB, subscriber ID, group number, plan type, and payer order (primary/secondary/tertiary).

Coordination of benefits (COB) birthday rule: for dependent children of parents with birthdays on different days, the parent with the earlier birthday in the calendar year is primary.

Medicare Secondary Payer (MSP): Medicare pays secondary when the employer group health plan is based on current employment and the employer has 20+ employees (or 100+ for disability-based MSP).

Real-time eligibility (270/271) verifies active coverage, copay, deductible remaining, and PCP assignment at or before the point of service.

Insurance card front/back capture must include payer phone, claims address, and any carve-out (behavioral, pharmacy, vision) administrator.

Patient identifiers require two-point verification (name plus DOB or MRN) before any service or record release.

Advance Beneficiary Notice (ABN) is required for Medicare items likely to be denied as not medically necessary; without it, the patient cannot be billed.

Registration accuracy rate = registrations without error / total registrations; front-end errors are the leading source of downstream denials.

ICD-10-CM codes the diagnosis (why); CPT/HCPCS code the service (what); ICD-10-PCS codes inpatient procedures only.

E/M level selection under 2021+ office/outpatient rules uses either medical decision making (MDM) or total time on the date of encounter.

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

Modifier 59 / X{EPSU} distinguishes distinct procedural services; used only when no more specific modifier applies.

NCCI edits: Column 1/Column 2 pairs are bundling edits; a modifier may bypass only if the services are clinically distinct.

Global surgical package includes pre-op, intra-op, and post-op care; modifiers 24, 25, 57, 58, 78, 79 handle exceptions.

Charge capture lag and charge master accuracy directly affect clean-claim rate; charges should post within 24-72 hours of service.

Medical necessity is established by documentation supporting the diagnosis linked to the CPT/HCPCS billed.

CMS-1500 (02/12) is used for professional claims; UB-04/CMS-1450 for institutional claims.

837P (professional) and 837I (institutional) are the HIPAA X12 electronic claim transactions; 835 is the remittance advice.

Clean claim rate = claims accepted on first submission / total claims submitted; a top-tier KPI target is 95% or higher.

Clearinghouse edits (front-end) catch data errors before payer submission; payer edits (back-end) catch coverage and coding issues.

Timely filing limits vary by payer (commonly 90-180 days from date of service or discharge); missing them forfeits payment.

Claim scrubber rules mirror NCCI, MUE, and payer-specific policies; edits should be resolved, not overridden, before submission.

Electronic claim rejections (front-end) differ from denials (adjudicated); rejections are corrected and resubmitted, denials are appealed or corrected.

Claim frequency codes: 1 = original, 7 = replacement, 8 = void/cancel; incorrect frequency codes cause duplicate or rejected claims.

Medicare physician fee schedule payment = (work RVU x GPCI + PE RVU x GPCI + MP RVU x GPCI) x conversion factor.

Inpatient DRG payment = DRG relative weight x hospital base rate (plus IME/DSH/outlier adjustments where applicable).

OPPS pays hospital outpatient services by APC; packaging rules bundle many items into the primary service.

Per diem and case rate contracts pay a fixed amount per day or per case regardless of charges.

Allowed amount = lesser of billed charge or fee schedule/contract rate; payment = allowed minus patient responsibility.

Contractual adjustment (write-off) = billed charges minus allowed amount; it is not collectible from the patient.

Sequential vs. concurrent payer adjudication: COB order determines which payer pays first and what the secondary considers.

Case-mix index (CMI) reflects the average DRG weight of a hospital's inpatient population and drives expected reimbursement.

Denial categories: registration/eligibility, coding, medical necessity, authorization, timely filing, and duplicate.

Denial rate = denied claims / total claims submitted; root-cause trending prevents repeat denials.

Appeal levels for Medicare: redetermination (MAC), reconsideration (QIC), ALJ hearing, Medicare Appeals Council, federal court.

First-level appeal must typically be filed within 120 days of the remittance advice for Medicare redeterminations.

CARC (claim adjustment reason code) and RARC (remittance advice remark code) identify the reason for denial and the corrective action.

Peer-to-peer review can overturn medical necessity denials before or during formal appeal.

Preventable denials (registration, eligibility, auth) should be tracked separately from clinical denials to guide process improvement.

Write-off authority thresholds and appeal ROI (expected recovery vs. cost to appeal) determine whether to pursue or abandon a denial.

Days in A/R = (total A/R / total charges) x days in period; a common benchmark is under 35-40 days.

A/R aging buckets: 0-30, 31-60, 61-90, 91-120, and 120+ days; the 90+ bucket is the highest-risk segment.

Clean claim rate, first-pass resolution rate, and denial rate are the primary leading indicators of A/R health.

Collection agency placement typically occurs after internal collection efforts and a defined aging threshold (e.g., 120-180 days).

Financial hardship and charity care policies must be applied before aggressive collection; IRS 501(r) requires screening for financial assistance.

Small balance write-off policies set a dollar threshold below which pursuit is not cost-effective.

Net collection rate = payments / (charges - contractual adjustments); a target is 96% or higher.

A/R follow-up should be driven by payer-specific tickler files rather than uniform calendar intervals.

Patient responsibility components: copay, coinsurance, deductible, and non-covered services.

Point-of-service collection and pre-service financial clearance improve cash and reduce bad debt.

Price transparency: hospitals must post standard charges; patients may request a good-faith estimate for scheduled services.

Financial assistance policies (FAP) and charity care eligibility are based on income as a percentage of the federal poverty level.

Payment plans should be documented, with terms, and monitored for adherence.

Medicare ABN informs the patient in advance that a service may be non-covered and shifts liability only if properly executed.

Copay vs. coinsurance: copay is a fixed dollar amount; coinsurance is a percentage of the allowed amount.

Patient estimates should be based on allowed amounts, not billed charges, to avoid over-collection and refunds.

False Claims Act liability includes knowingly presenting or causing to be presented a false claim; penalties are per-claim plus treble damages.

Anti-Kickback Statute prohibits remuneration for referrals of federally payable items or services; intent is required.

Stark Law (Physician Self-Referral) is a strict-liability civil statute prohibiting referrals when a financial relationship exists, absent an exception.

Civil Monetary Penalties Law, Exclusion Statute, and Beneficiary Inducement CMP are additional federal enforcement tools.

HIPAA Privacy and Security Rules govern PHI use, disclosure, and safeguards; minimum necessary standard applies.

Compliance program elements (seven OIG elements) include written policies, a compliance officer, training, auditing, and enforcement/discipline.

RAC, MAC, and UPIC audits target high-risk billing patterns; audit findings should trigger corrective action plans.

Exclusion screening (OIG LEIE, SAM) is required before employing or contracting with providers.

EHR/PM system integration must maintain a single source of truth for patient, encounter, and charge data.

Interface errors (HL7 ADT, orders, results) are a common source of missing charges and duplicate records.

Data integrity controls include edit checks, audit trails, and reconciliation of charges to services rendered.

Charge master maintenance requires version control and scheduled annual review to reflect code and rate changes.

Business continuity and disaster recovery plans protect revenue cycle operations and PHI availability.

Role-based access and audit logging support HIPAA Security Rule compliance and fraud detection.

Dashboards should reconcile source-system totals to reported KPIs; unexplained variance signals data quality problems.

Interoperability standards (HL7 FHIR, X12) enable data exchange but require mapping validation to prevent translation errors.

Revenue cycle spans pre-service (scheduling, eligibility), mid-service (coding, charge capture), and post-service (billing, collections).

Key KPIs: clean claim rate, denial rate, days in A/R, net collection rate, and cost to collect.

Cost to collect = total revenue cycle cost / total cash collected; lower is better.

First-pass resolution rate measures claims paid on first submission without rework.

Root-cause analysis (fishbone, 5 Whys) identifies process failures behind denials and A/R aging.

PDSA/Plan-Do-Study-Act and Lean/Six Sigma methods drive measurable revenue cycle improvement.

Benchmarking against peer organizations (HFMA MAP keys, MGMA) contextualizes performance.

Front-end accuracy has the greatest leverage: errors at registration propagate to coding, billing, and collections.

Registration data elements that drive reimbursement: legal name, DOB, subscriber ID, group number, plan type, and payer order (primary/secondary/tertiary).

Coordination of benefits (COB) birthday rule: for dependent children of parents with birthdays on different days, the parent with the earlier birthday in the calendar year is primary.

Medicare Secondary Payer (MSP): Medicare pays secondary when the employer group health plan is based on current employment and the employer has 20+ employees (or 100+ for disability-based MSP).

Real-time eligibility (270/271) verifies active coverage, copay, deductible remaining, and PCP assignment at or before the point of service.

Insurance card front/back capture must include payer phone, claims address, and any carve-out (behavioral, pharmacy, vision) administrator.

Patient identifiers require two-point verification (name plus DOB or MRN) before any service or record release.

Advance Beneficiary Notice (ABN) is required for Medicare items likely to be denied as not medically necessary; without it, the patient cannot be billed.

Registration accuracy rate = registrations without error / total registrations; front-end errors are the leading source of downstream denials.

ICD-10-CM codes the diagnosis (why); CPT/HCPCS code the service (what); ICD-10-PCS codes inpatient procedures only.

E/M level selection under 2021+ office/outpatient rules uses either medical decision making (MDM) or total time on the date of encounter.

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

Modifier 59 / X{EPSU} distinguishes distinct procedural services; used only when no more specific modifier applies.

NCCI edits: Column 1/Column 2 pairs are bundling edits; a modifier may bypass only if the services are clinically distinct.

Global surgical package includes pre-op, intra-op, and post-op care; modifiers 24, 25, 57, 58, 78, 79 handle exceptions.

Charge capture lag and charge master accuracy directly affect clean-claim rate; charges should post within 24-72 hours of service.

Medical necessity is established by documentation supporting the diagnosis linked to the CPT/HCPCS billed.

CMS-1500 (02/12) is used for professional claims; UB-04/CMS-1450 for institutional claims.

837P (professional) and 837I (institutional) are the HIPAA X12 electronic claim transactions; 835 is the remittance advice.

Clean claim rate = claims accepted on first submission / total claims submitted; a top-tier KPI target is 95% or higher.

Clearinghouse edits (front-end) catch data errors before payer submission; payer edits (back-end) catch coverage and coding issues.

Timely filing limits vary by payer (commonly 90-180 days from date of service or discharge); missing them forfeits payment.

Claim scrubber rules mirror NCCI, MUE, and payer-specific policies; edits should be resolved, not overridden, before submission.

Electronic claim rejections (front-end) differ from denials (adjudicated); rejections are corrected and resubmitted, denials are appealed or corrected.

Claim frequency codes: 1 = original, 7 = replacement, 8 = void/cancel; incorrect frequency codes cause duplicate or rejected claims.

Medicare physician fee schedule payment = (work RVU x GPCI + PE RVU x GPCI + MP RVU x GPCI) x conversion factor.

Inpatient DRG payment = DRG relative weight x hospital base rate (plus IME/DSH/outlier adjustments where applicable).

OPPS pays hospital outpatient services by APC; packaging rules bundle many items into the primary service.

Per diem and case rate contracts pay a fixed amount per day or per case regardless of charges.

Allowed amount = lesser of billed charge or fee schedule/contract rate; payment = allowed minus patient responsibility.

Contractual adjustment (write-off) = billed charges minus allowed amount; it is not collectible from the patient.

Sequential vs. concurrent payer adjudication: COB order determines which payer pays first and what the secondary considers.

Case-mix index (CMI) reflects the average DRG weight of a hospital's inpatient population and drives expected reimbursement.

Denial categories: registration/eligibility, coding, medical necessity, authorization, timely filing, and duplicate.

Denial rate = denied claims / total claims submitted; root-cause trending prevents repeat denials.

Appeal levels for Medicare: redetermination (MAC), reconsideration (QIC), ALJ hearing, Medicare Appeals Council, federal court.

First-level appeal must typically be filed within 120 days of the remittance advice for Medicare redeterminations.

CARC (claim adjustment reason code) and RARC (remittance advice remark code) identify the reason for denial and the corrective action.

Peer-to-peer review can overturn medical necessity denials before or during formal appeal.

Preventable denials (registration, eligibility, auth) should be tracked separately from clinical denials to guide process improvement.

Write-off authority thresholds and appeal ROI (expected recovery vs. cost to appeal) determine whether to pursue or abandon a denial.

Days in A/R = (total A/R / total charges) x days in period; a common benchmark is under 35-40 days.

A/R aging buckets: 0-30, 31-60, 61-90, 91-120, and 120+ days; the 90+ bucket is the highest-risk segment.

Clean claim rate, first-pass resolution rate, and denial rate are the primary leading indicators of A/R health.

Collection agency placement typically occurs after internal collection efforts and a defined aging threshold (e.g., 120-180 days).

Financial hardship and charity care policies must be applied before aggressive collection; IRS 501(r) requires screening for financial assistance.

Small balance write-off policies set a dollar threshold below which pursuit is not cost-effective.

Net collection rate = payments / (charges - contractual adjustments); a target is 96% or higher.

A/R follow-up should be driven by payer-specific tickler files rather than uniform calendar intervals.

Patient responsibility components: copay, coinsurance, deductible, and non-covered services.

Point-of-service collection and pre-service financial clearance improve cash and reduce bad debt.

Price transparency: hospitals must post standard charges; patients may request a good-faith estimate for scheduled services.

Financial assistance policies (FAP) and charity care eligibility are based on income as a percentage of the federal poverty level.

Payment plans should be documented, with terms, and monitored for adherence.

Medicare ABN informs the patient in advance that a service may be non-covered and shifts liability only if properly executed.

Copay vs. coinsurance: copay is a fixed dollar amount; coinsurance is a percentage of the allowed amount.

Patient estimates should be based on allowed amounts, not billed charges, to avoid over-collection and refunds.

False Claims Act liability includes knowingly presenting or causing to be presented a false claim; penalties are per-claim plus treble damages.

Anti-Kickback Statute prohibits remuneration for referrals of federally payable items or services; intent is required.

Stark Law (Physician Self-Referral) is a strict-liability civil statute prohibiting referrals when a financial relationship exists, absent an exception.

Civil Monetary Penalties Law, Exclusion Statute, and Beneficiary Inducement CMP are additional federal enforcement tools.

HIPAA Privacy and Security Rules govern PHI use, disclosure, and safeguards; minimum necessary standard applies.

Compliance program elements (seven OIG elements) include written policies, a compliance officer, training, auditing, and enforcement/discipline.

RAC, MAC, and UPIC audits target high-risk billing patterns; audit findings should trigger corrective action plans.

Exclusion screening (OIG LEIE, SAM) is required before employing or contracting with providers.

EHR/PM system integration must maintain a single source of truth for patient, encounter, and charge data.

Interface errors (HL7 ADT, orders, results) are a common source of missing charges and duplicate records.

Data integrity controls include edit checks, audit trails, and reconciliation of charges to services rendered.

Charge master maintenance requires version control and scheduled annual review to reflect code and rate changes.

Business continuity and disaster recovery plans protect revenue cycle operations and PHI availability.

Role-based access and audit logging support HIPAA Security Rule compliance and fraud detection.

Dashboards should reconcile source-system totals to reported KPIs; unexplained variance signals data quality problems.

Interoperability standards (HL7 FHIR, X12) enable data exchange but require mapping validation to prevent translation errors.

Revenue cycle spans pre-service (scheduling, eligibility), mid-service (coding, charge capture), and post-service (billing, collections).

Key KPIs: clean claim rate, denial rate, days in A/R, net collection rate, and cost to collect.

Cost to collect = total revenue cycle cost / total cash collected; lower is better.

First-pass resolution rate measures claims paid on first submission without rework.

Root-cause analysis (fishbone, 5 Whys) identifies process failures behind denials and A/R aging.

PDSA/Plan-Do-Study-Act and Lean/Six Sigma methods drive measurable revenue cycle improvement.

Benchmarking against peer organizations (HFMA MAP keys, MGMA) contextualizes performance.

Front-end accuracy has the greatest leverage: errors at registration propagate to coding, billing, and collections.