QBRS key terms

The complete set of administrative and clinical steps a healthcare organization performs from the moment a patient schedules an appointment through final payment of the balance, including registration, coding, billing, and collections.

A claim submitted with all required data elements present, accurate, and formatted according to payer rules so that it can be processed without rejection or manual intervention.

The portion of the revenue cycle that occurs before services are billed, covering scheduling, registration, insurance verification, authorization, and point-of-service patient collections.

The portion of the revenue cycle that begins after the encounter, covering charge capture, coding, claim submission, payment posting, denial management, and final account resolution.

A measurable value, such as days in accounts receivable or clean claim rate, used to track whether a revenue cycle process is performing at an acceptable standard over time.

The intake process in which demographic, insurance, and contact information is collected and entered into the practice management system to create or update the patient's record.

The process of confirming with a payer that a patient's coverage is active on the date of service and that the planned service is a covered benefit under the plan.

A payer inquiry that confirms specifics of a patient's plan, such as deductible remaining, copayment amounts, coinsurance percentage, and out-of-pocket maximum status.

A payer's advance approval for a specific service, procedure, or medication, required before care is delivered so that payment is not later denied as not medically necessary.

A formal request from a primary care provider directing a patient to a specialist or other service, which some managed care plans require before the specialist visit will be covered.

The rules that determine which of a patient's multiple insurance plans pays first and how the remaining balance is submitted to the secondary payer.

The insurance plan that processes and pays a claim first, before any secondary or tertiary coverage is billed for the remaining patient or plan liability.

The determination that a service is reasonable, clinically appropriate, and supported by the patient's documented condition, which payers require before they will cover the service.

A five-character numeric or alphanumeric code from the Current Procedural Terminology system that describes a specific medical service, procedure, or diagnostic test for billing purposes.

A standardized alphanumeric code used to report a patient's diagnosis, symptoms, or reason for the encounter, supporting medical necessity for the services billed.

A code set maintained for reporting supplies, drugs, durable medical equipment, and certain services not described by CPT, using Level II alphanumeric codes.

The process of recording the services, supplies, and procedures delivered during an encounter so they can be translated into billable codes on the claim.

An internal list of every billable item and service a facility offers, each linked to a price and a code, used to generate charges for services provided.

A two-character code appended to a procedure code to communicate a specific circumstance, such as a bilateral procedure or a distinct service, that affects how the claim is paid.

Software that reviews claims for missing data, coding conflicts, and payer-specific edits before submission, flagging errors so they can be corrected and the claim submitted clean.

An intermediary that receives electronic claims from providers, checks them against formatting and payer edits, and routes them to the correct insurance payer.

The standardized electronic exchange of healthcare transactions such as claims, remittances, and eligibility inquiries between providers and payers in a common format.

A claim returned before adjudication because it failed a formatting or data requirement, meaning it was never processed and must be corrected and resubmitted.

A payer's decision after adjudication to refuse payment on a claim, often citing medical necessity, authorization, eligibility, or coding reasons that must be appealed or corrected.

A formal request asking a payer to reconsider a denied claim, supported by clinical documentation or corrected information, following the payer's stated appeal process and deadlines.

The systematic process of categorizing, investigating, correcting, and appealing denied claims, while tracking root causes to prevent similar denials in the future.

A statement from an insurer to the patient and provider showing what was billed, what the plan paid, and what the patient owes, along with any denial reasons.

The total money owed to a provider for services already delivered but not yet paid, tracked by age and payer to measure collection performance.

A measure of how long, on average, it takes a provider to collect payment after a service is billed, calculated by dividing total A/R by average daily charges.

A report that groups unpaid balances by how long they have been outstanding, such as 0-30, 31-60, and 61-90 days, to prioritize collection follow-up.

The portion of a bill the patient must pay, including copayments, coinsurance, deductibles, and non-covered services, after the insurer has processed the claim.

A fixed dollar amount a patient pays at the time of service, as defined by the health plan, separate from any deductible or coinsurance obligation.

An electronic or paper document from a payer that accompanies payment and itemizes each claim's allowed amount, paid amount, adjustments, and denial reasons.

The process of recording payer and patient payments, along with contractual adjustments, against the correct claims and accounts in the billing system.

A federal law that imposes liability on persons and organizations that knowingly submit false or fraudulent claims for payment to government healthcare programs.

A federal law prohibiting the exchange of anything of value intended to induce referrals or the ordering of items and services paid for by federal healthcare programs.

A federal law that prohibits physicians from referring patients to entities in which they or their immediate family have a financial relationship for designated health services, absent an exception.

Assigning a higher-level or more expensive code than the documentation supports in order to increase payment, which is a form of healthcare fraud.

A federal law that sets national standards for protecting patients' protected health information and governs how it may be used, disclosed, and safeguarded.

Individually identifiable health information held or transmitted by a covered entity or business associate, which must be protected and disclosed only under permitted circumstances.

A provider's written guidelines for offering discounts, payment plans, or charity care to patients who cannot pay, often based on income and family size.

An agreement allowing a patient to pay an outstanding balance in scheduled installments over time rather than in a single lump sum.

The requirement that providers publish or make available their standard charges and, for insured patients, a good-faith estimate of expected out-of-pocket costs before service.