CHBME key terms

The process of documenting every service, supply, and procedure provided to a patient and converting it into a billable code so it can appear on a claim. Missed charges create lost revenue.

The organization's internal catalogue listing each billable item with its code, description, and price. It links clinical services to claim lines and must be reviewed regularly for accuracy and compliance.

A claim containing all required data elements, correctly formatted, with no errors or missing information, so a payer can adjudicate it without manual intervention or requests for additional data.

An automated pre-submission check that compares a claim against payer rules and edits, flagging coding conflicts, missing fields, or eligibility problems before the claim leaves the organization.

A rule-driven warning or hard stop that prevents or flags a claim line during processing, such as a code pair that cannot be billed together or a missing modifier.

The electronic or paper statement a payer sends with payment, itemizing each claim line, the amount paid, and any adjustment or denial reason. Also called an ERA when transmitted electronically.

A statement, often sent to the patient, summarizing what a payer allowed, paid, and left as patient responsibility for a service. It is not a bill but explains the cost sharing.

A standard code on a remittance advice explaining why a billed amount was reduced, denied, or shifted to another party, such as a contractual write-off or a coverage determination.

The difference between the provider's billed charge and the amount a payer's contracted rate permits. It is written off and not billed to the patient when the provider is in network.

A published list of payment amounts a payer will allow for specific services, often varying by site of service and geography. It forms the basis of contracted reimbursement rates.

A payer's refusal to pay all or part of a claim, accompanied by a reason code. Denials may stem from eligibility, coding, authorization, or medical necessity issues and require appeal or correction.

A formal request that a payer reconsider a denied or underpaid claim, supported by clinical documentation and the relevant policy or contract language. Appeals follow payer-specific levels and deadlines.

The deadline, set by payer contract or regulation, by which a claim or appeal must be received. Claims submitted after this limit are generally denied regardless of merit.

A payer's advance approval required before certain services, drugs, or procedures are performed. Without it, the payer may deny payment even when the service was medically appropriate.

The determination that a service is reasonable and required to diagnose or treat a patient's condition according to accepted standards. Payers review documentation to confirm it before paying.

The record of a patient encounter in the medical record, including history, findings, and the provider's assessment and plan. It supports the codes billed and defends payment on review.

Translating documented diagnoses and procedures into standardized alphanumeric codes used on claims. Accurate coding depends on the medical record and drives both reimbursement and quality reporting.

A two-character code appended to a procedure code to indicate a circumstance that changes how the service is paid, such as a distinct site, laterality, or a professional component only.

The rules determining which of a patient's multiple insurance plans pays first and how the secondary plan pays after the primary. Correct order prevents overpayment and duplicate billing.

Confirming before or at the time of service that a patient's insurance is active and that the service is covered under the plan. Failures here are a leading cause of denials.

The portion of a bill the patient owes after insurance, including copayments, coinsurance, deductibles, and non-covered services. It is distinct from amounts written off contractually.

A fixed dollar amount a patient pays for a covered service at the time it is received, as set by the health plan. It is separate from coinsurance, which is a percentage.

The share of a covered service's allowed amount that a patient pays, expressed as a percentage, after any deductible is met. The plan pays the remainder under its benefit design.

The amount a patient must pay out of pocket for covered services before the health plan begins paying its share. Deductibles reset each benefit period, usually annually.

The total money owed to the organization for services already delivered but not yet paid. Aging reports break it into time buckets to reveal collection problems and follow-up priorities.

A report grouping unpaid claims by how long they have been outstanding, typically in 30-day buckets. It highlights stalled claims and guides follow-up work by the billing team.

A measure of how many days, on average, it takes to collect payment after a service is billed. Lower values generally indicate faster cash flow and more efficient follow-up.

The discipline of ensuring that all legitimate services are captured, coded, and billed correctly while preventing compliance risk. It bridges clinical operations, coding, and finance.

The proportion of an organization's revenue or volume coming from each payer type, such as commercial, Medicare, and Medicaid. It shapes contracting strategy and financial risk.

Collecting patient cost sharing, such as copayments or prior balances, at the time care is delivered rather than later by mail. It improves cash flow and reduces bad debt.

Unpaid patient balances a provider deems uncollectible after reasonable collection efforts. It is treated differently from charity care for accounting and reporting purposes.

Free or discounted care given to patients who cannot afford to pay under the organization's financial assistance policy. It is tracked separately from bad debt and contractual allowances.

The standardized electronic exchange of healthcare transactions such as claims, remittances, and eligibility checks between providers and payers, reducing paperwork and manual errors.

The full set of administrative steps from scheduling and registration through coding, billing, payment posting, and collections. Each stage affects how much of the billed amount is ultimately collected.

Recording payer and patient payments against the correct claim lines and applying adjustments so that each account balance reflects what remains owed.

A payment that falls short of the contracted or allowed amount for a service. Detecting underpayments requires comparing remittance data against the fee schedule and contract terms.

Removing an amount from a patient or payer balance because it will not be collected, for reasons such as contractual allowance, small-balance policy, or charity adjustment.

The amount owed directly by the patient after insurance processing, including copays, coinsurance, deductibles, and non-covered services. It requires its own collection workflow.