PMRP key terms

The hospital's internal catalog listing every billable item and service with its charge code, price, revenue code, and CPT or HCPCS assignment. It drives claim line generation, so errors here propagate directly into reimbursement and compliance risk.

A four-digit NUBC code on a UB-04 claim line identifying the category of service provided, such as room and board or pharmacy. It tells the payer what kind of charge is being billed independent of the procedure code.

A federal law making it a crime to knowingly offer, pay, solicit, or receive anything of value to induce referrals of items or services covered by federal healthcare programs. Violations can trigger criminal penalties and exclusion from Medicare.

Physician self-referral prohibition barring doctors from referring Medicare patients for designated health services to entities in which they or immediate family hold a financial relationship, unless a regulatory exception applies.

A federal statute imposing liability on parties who knowingly submit or cause submission of false or fraudulent claims to government payers. It includes qui tam provisions letting private relators sue and share recovered funds.

A standardized Medicare notice a provider gives a beneficiary before delivering a service that may not be covered, so the patient can choose to proceed and accept financial responsibility. Proper use shifts liability from provider to patient.

The determination that a service is reasonable and required to diagnose or treat a condition according to accepted standards of care. Payers deny claims lacking documented support, so clinical documentation must justify each billed service.

A payer requirement that specific services be approved before delivery, often for imaging, surgery, or specialty drugs. Missing or expired authorizations are a leading cause of front-end denials and lost revenue.

The process of confirming a patient's insurance coverage, benefits, and effective dates before or at the point of service. Accurate verification prevents bad debt and denials caused by inactive or terminated coverage.

Requesting and accepting patient payment for copays, coinsurance, and estimated balances at the time care is delivered. It improves cash flow and reduces the cost of later collection efforts.

Guiding patients through coverage options, cost estimates, payment plans, and charity care eligibility. Counselors help uninsured and underinsured patients resolve balances before they become bad debt.

Discounted or free care provided to patients who cannot pay, typically governed by a written financial assistance policy. Nonprofit hospitals must follow specific rules for notifying and screening patients before pursuing collections.

The portion of a bill the patient owes after payer adjudication, including copays, coinsurance, deductibles, and non-covered services. Accurate estimation and clear communication reduce write-offs and complaints.

A program that reviews medical records concurrently and retrospectively to ensure diagnoses and procedures are documented completely, accurately, and specifically. Better documentation supports correct code assignment, severity capture, and compliant reimbursement.

A formal, non-leading communication from a CDI specialist or coder to a provider asking for clarification or additional documentation. Compliant queries are written, clinically grounded, and preserved in the record.

Assigning codes for office visits and other cognitive services based on documented medical decision-making or time. Current guidelines determine level selection, and errors here are a frequent audit target.

The AMA-maintained code set describing medical services and procedures, used for outpatient and physician billing. Category I codes are five digits; Category II track performance; Category III cover emerging technology.

A code set with Level I being CPT and Level II being alphanumeric codes for supplies, drugs, and services not in CPT. Level II codes are maintained by CMS and used across payers.

A two-character suffix appended to a procedure code to report a meaningful circumstance, such as a distinct service or bilateral procedure. Correct use prevents bundling edits from denying legitimate separate payment.

CMS edits that define code pairs not generally billable together and specify whether a modifier may override the edit. Understanding these edits helps coders avoid automatic denials and improper unbundling.

The process of recording every service, supply, and drug delivered so it can be billed. Missed or late charges cause lost revenue, while duplicate or inaccurate charges create compliance exposure.

Charges entered after the service date, often because documentation or supply capture lagged. They must be reconciled and posted to the correct account to avoid underbilling or duplicate claims.

The standard institutional claim form (CMS-1450) used to bill hospitals and facilities to payers. It carries revenue codes, condition codes, and occurrence codes in addition to procedure and diagnosis information.

The standard paper and electronic claim form used by physicians and suppliers to bill professional services. It carries CPT or HCPCS codes, diagnosis pointers, and place-of-service information.

A claim submitted with all required data elements correct and complete so the payer can adjudicate it without requesting more information. Clean claim rates directly affect days in accounts receivable.

Automated pre-submission edits that check claims for missing fields, code mismatches, eligibility issues, and payer-specific rules. Scrubbing catches errors before they become denials.

A payer statement detailing how a claim was processed, including allowed amounts, paid amounts, adjustments, and patient responsibility. Remittance advice data drives posting and denial identification.

The electronic transaction (X12 835) that transmits payment, adjustment, and denial information from payer to provider. It is the primary source for automated payment posting and reconciliation.

Recording payer and patient payments and adjustments against the correct claim lines and accounts. Accurate posting keeps balances reliable and supports denial follow-up and reconciliation.

Comparing posted payments and adjustments to bank deposits, remittance files, and expected contract amounts to confirm everything balances. Unreconciled variances signal posting errors, missed payments, or underpayments.

A payer payment below the contracted or expected reimbursement rate. Systematic underpayment review recovers revenue that would otherwise be written off silently.

Maintaining payer-specific fee schedules and reimbursement terms in the billing system so expected payments can be calculated and compared to actual remittances. It underpins variance and underpayment analysis.

The structured process of identifying, categorizing, appealing, and preventing claim denials. Root-cause analysis by denial reason and payer drives sustainable reductions in rework and write-offs.

A standardized or payer-specific code explaining why a claim or line was denied, such as missing authorization or non-covered service. Grouping denials by code reveals fixable front-end or coding problems.

A formal request that a payer reconsider a denied or underpaid claim, supported by clinical documentation and policy citations. Appeals follow payer-specific levels and deadlines that must be tracked carefully.

A metric estimating the average number of days to collect outstanding balances, calculated as net A/R divided by average daily net revenue. Rising A/R days signal collection or denial problems.

A report grouping unpaid claims by how long they have been outstanding, typically in 30-day buckets. It highlights accounts at risk of timely filing deadlines or payer follow-up limits.

The payer's deadline for submitting an initial claim or appeal. Missing it usually forfeits payment rights, so tracking filing limits is essential to revenue protection.

A quantifiable measure used to track revenue cycle performance, such as clean claim rate, denial rate, or net collection rate. Dashboards compare results to targets and benchmarks over time.

The percentage of claims or charges denied by payers in a period. Tracking it by payer and reason code shows where process improvements will recover the most revenue.

A risk-adjustment model grouping diagnoses to predict patient cost, used in Medicare Advantage and other risk-based payments. Complete, accurate diagnosis capture directly affects capitated revenue.

Federal law setting privacy and security standards for protected health information, including administrative, physical, and technical safeguards. Revenue cycle staff handle PHI daily and must follow minimum-necessary and access rules.

Individually identifiable health information held or transmitted by covered entities and their business associates. Its use and disclosure are restricted by HIPAA privacy and security rules.

Restricting system permissions so staff can view only the data needed for their job function. It supports HIPAA minimum-necessary compliance and limits insider misuse of patient and financial data.

The standardized electronic exchange of transactions such as claims (837), remittances (835), and eligibility inquiries (270/271) between providers and payers. It replaces paper workflows and enables automation.

The ability of different systems and organizations to exchange and use health data meaningfully. It supports real-time eligibility, clinical data sharing, and coordinated revenue cycle workflows.

A network or organization enabling electronic sharing of clinical data among providers, payers, and other entities. It improves documentation completeness and supports medical necessity validation.