CHAM flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

Real-time eligibility transaction

The 270/271 electronic exchange that confirms a patient's active coverage, plan type, and benefits before service. It should run at pre-registration and again on the date of service.

Clean claim rate

The percentage of claims accepted on first submission without edits or rework. It is a primary front-end quality indicator because rejected claims delay payment and add cost.

Two-midnight rule

A CMS rule stating inpatient admission is generally appropriate when a physician expects the stay to span at least two midnights. Shorter expected stays default to outpatient or observation.

Days in accounts receivable

Total A/R divided by average daily charges, expressed in days. Higher values indicate slower cash conversion and often point to front-end or follow-up process failures.

Minimum necessary standard

A HIPAA Privacy Rule requirement limiting PHI access and disclosure to the least amount needed for the purpose. Treatment, payment, and operations disclosures to providers and payers are excepted.

Point-of-service collection rate

Patient payments collected at or before the date of service divided by total patient responsibility. It measures how well front-end staff estimate and collect patient obligations.

Prior authorization validity

A PA applies only to the specific procedure code, date range, and sometimes facility approved. A different code or expired window requires a new authorization.

Denial rate

Denied claims divided by total claims submitted. Root causes typically fall into registration, eligibility, authorization, coding, or medical necessity categories.

Anti-Kickback Statute

A federal law prohibiting remuneration intended to induce referrals for items or services reimbursable by federal health programs. Violations can trigger criminal and civil penalties.

Stark Law

A strict liability statute barring physician self-referral for designated health services paid by Medicare, unless a specific regulatory exception applies to the arrangement.

Breach notification timeline

Covered entities must notify affected individuals without unreasonable delay and no later than 60 days after discovering a breach of unsecured protected health information.

Net patient revenue

Gross charges minus contractual allowances, discounts, and charity care. Bad debt is a separate expense and is not deducted as a contractual allowance.

Charge lag

The number of days between service delivery and charge posting. Long lags delay claim submission and can push claims past payer filing deadlines.

Clean registration data

Accurate patient identifiers, verified insurance, and correct visit reason captured at scheduling. Errors here cascade into eligibility, authorization, and denial problems.

Medical necessity screening

Applying payer or clinical criteria at scheduling to confirm the ordered service meets coverage rules. It prevents necessity denials before the service is delivered.

Cost-to-collect

Total collection expenses divided by total collections. Rising cost-to-collect with flat yield signals an inefficient follow-up or appeals process.

PDSA cycle

Plan-Do-Study-Act: a small-scale test of a change with a documented prediction and measured result. Successful tests are scaled; failures inform the next iteration.

Span of control

The number of direct reports assigned to a manager. Wider spans require stronger standard work and self-service tools to maintain oversight quality.

Productivity ratio

A measure such as registrations per FTE or accounts worked per FTE per day. Variance from target identifies over- or under-staffing in a work unit.

Seven compliance program elements

Written policies, a compliance officer, training, communication lines, auditing and monitoring, enforcement and discipline, and response with corrective action.

Root cause analysis

A structured method separating proximate cause from underlying system cause. Repeat denials usually trace to a front-end data defect rather than payer behavior.

First-pass resolution rate

The percentage of claims paid without rework such as appeals, corrections, or resubmission. It complements clean claim rate by measuring payer-side outcomes.

Underpayment recovery

Comparing remittance against the contracted fee schedule or case rate and appealing variances beyond contract tolerance. It protects expected net revenue.

Reverse false claim

A False Claims Act provision making it liability to knowingly retain an overpayment. Identified overpayments must generally be returned within 60 days.

Conditions of Participation

CMS minimum health and safety standards required for Medicare participation. They cover patient rights, grievance processes, infection control, and quality oversight.

KPI pairing principle

Pairing a volume metric with a quality metric on a dashboard prevents gaming. Registrations alone can rise while error rates quietly increase.

Capacity planning

Forecasting volume by day of week and season, then aligning staff schedules to peak arrival patterns. It reduces wait times and abandonment in patient access.

Change management plan

Stakeholder mapping, communication, training, and go-live support required for any workflow or system change. Skipping steps causes adoption failure and rework.

Duplicate medical record rate

The share of patient records created in error for an existing patient. High rates fragment clinical history and cause claim and billing errors.

Referral visit limits

A referral is valid only for the payer-specified number of visits and time window. Exceeding either requires a new referral or authorization.

Cash acceleration levers

Electronic remittance auto-posting, claim scrubbing edits, and payer portal follow-up. They replace manual work and shorten the time from submission to cash.

Financial assistance policy

A written, publicized policy defining charity care eligibility and application. Nonprofit hospitals must apply it consistently under 501(r) requirements.