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CHAM: Revenue Cycle Management

CHAM · Work through your exam, one topic at a time.

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Revenue Cycle Management

What this domain tests

Revenue Cycle Management tests how patient access work becomes a paid, compliant claim. Expect questions on charge capture and the chargemaster, coding and billing interfaces, claim scrubbing and submission, remittance posting, denial prevention and management, patient balances, and the metrics that show whether the cycle is healthy.

Core rules and concepts

  • The revenue cycle has front-end, mid-cycle, and back-end work. Registration, eligibility, authorization, and medical necessity errors often surface as back-end denials.
  • The chargemaster must map each billable service to the correct code, description, and price. Charges should be captured when the service is delivered, not weeks later.
  • Use standard claim formats (837 for institutional or professional claims) and reconcile electronic remittance advice (835) to posted payments.
  • Track clean claim rate, initial denial rate, days in accounts receivable, net collection rate, aged A/R, and denial overturn rate.
  • Work denials by root cause and accountable owner. Read the claim adjustment reason code (CARC) and remittance advice remark code (RARC); correct and rebill, appeal within timely filing, or write off only when justified.
  • Reconcile patient payments, refunds, and credits; follow policy for financial counseling and point-of-service collection.

Worked example

An outpatient infusion claim is denied with a missing-information reason code. The biller's first instinct is to resubmit unchanged. The manager instead traces the claim: the authorization was never linked at scheduling, so the payer has no approval on file. The team obtains a retro-authorization if the payer allows, corrects the claim, attaches the authorization, and rebills before the appeal deadline. The manager also adds an authorization field to the scheduling checklist and audits the next 20 infusion schedules.

Traps

Resubmitting without correcting the defect; writing off preventable denials to clear the queue; judging performance by gross charges rather than collections; and missing timely-filing deadlines while waiting on clinical documentation.