CHAM key terms

The front-end hospital function that registers patients, verifies eligibility and benefits, obtains authorizations, and collects point-of-service payments before and during a visit.

Completing demographic, insurance, and clinical intake data before the patient arrives so that eligibility, authorization, and financial counseling can occur in advance.

An electronic 270/271 transaction that confirms active coverage, plan type, copay and deductible status with the payer at or near the time of scheduling.

Payer approval obtained before a service, drug, or admission is delivered, confirming medical necessity and payment terms; missing authorization is a leading cause of denials.

The rules determining which payer pays first when a patient has multiple coverages, including birthday rules for dependent children and Medicare Secondary Payer order.

Collecting estimated patient responsibility, such as copays and deposits, at registration or discharge rather than billing after the encounter.

The completed package of verified eligibility, secured authorization, and communicated patient liability that allows a scheduled service to proceed with predictable reimbursement.

A planned inpatient stay arranged in advance, requiring preregistration, benefit verification, and often a payer utilization review notification before arrival.

The end-to-end process of capturing, billing, and collecting payment for services, spanning scheduling through final account resolution and analytics.

Recording every billable service, supply, and procedure performed during an encounter so that charges reconcile to clinical documentation before claim submission.

The internal master file of billable items with their codes, descriptions, and prices, which must be maintained to reflect current services and payer rules.

Automated pre-submission editing that checks a claim for missing data, code conflicts, and payer-specific rules to prevent avoidable rejections.

The percentage of claims accepted on first submission without rejection or edit, a core indicator of front-end and coding accuracy.

The structured process of categorizing, appealing, and preventing claim denials, with root-cause tracking fed back to registration, coding, and authorization workflows.

A payer-assigned code explaining why a claim was reduced or rejected, used to trend denial causes and target process improvement.

The payer's explanation of payment listing billed, allowed, paid, and patient-responsibility amounts plus adjustment and denial codes for each claim.

The average number of days outstanding balances remain uncollected, calculated by dividing total receivables by average daily net revenue.

A report that buckets unpaid claims by age, such as 0-30, 31-60, and 61-90 days, to prioritize follow-up and reveal payer slowdowns.

The portion of a bill the patient owes directly, including copays, coinsurance, deductible balances, and charges for the uninsured.

A scheduled installment arrangement allowing a patient to pay an outstanding balance over time, often governed by a written financial assistance policy.

The federal law whose Privacy and Security Rules govern how covered entities may use, disclose, and safeguard protected health information.

Individually identifiable health information held or transmitted by a covered entity or business associate in any form, subject to HIPAA privacy and security rules.

The HIPAA principle that only the least amount of protected health information needed for a purpose should be accessed, used, or disclosed.

A written notice describing how a covered entity may use and disclose health information and explaining patient rights, provided at first service.

A contract required under HIPAA that binds a vendor handling protected health information to safeguard it and report breaches.

The HIPAA obligation to notify affected individuals, regulators, and sometimes media within defined timeframes after an impermissible disclosure of unsecured health information.

The federal law requiring Medicare-participating hospitals to provide a medical screening exam and stabilizing treatment regardless of insurance or ability to pay.

The evaluation a hospital must perform under EMTALA to determine whether an emergency medical condition exists, provided without regard to payment.

A hospital's written policy defining eligibility, discounts, and application procedures for reduced-cost care for qualifying low-income patients.

Care provided at reduced or no charge to patients who cannot pay and who meet the organization's financial assistance eligibility criteria.

The determination that a service is reasonable, clinically appropriate, and consistent with accepted standards for the patient's condition, supporting payer coverage.

Adherence to official coding guidelines and payer rules, supported by audits and documentation review, to ensure accurate and defensible code assignment.

The review of admission necessity, level of care, and continued stay against payer criteria, often requiring concurrent notification to secure authorization.

A quantifiable metric tied to a strategic goal, such as clean claim rate or days in accounts receivable, used to monitor and steer revenue cycle performance.

A structured method for tracing a performance failure, such as a denial spike, back to the underlying workflow or system defect so it can be permanently corrected.

A disciplined cycle of measuring, redesigning, and re-measuring workflows, often using lean or plan-do-study-act methods, to reduce errors and rework.

A measure of output per staff member, such as registrations or accounts worked per hour, used to balance workload, staffing, and quality in access and billing teams.

A payer statement to the patient showing services processed, allowed amounts, payments, and remaining patient responsibility, often confused with a bill.