Revenue Cycle Management Glossary
A curated collection of terms that bridge the realms of blank.
Artificial Intelligence (AI) in RCM
What is Artificial Intelligence (AI) in RCM? Artificial Intelligence (AI) in RCM refers to the application of advanced algorithms, including Machine Learning (ML), to perform complex, cognitive tasks like predictive analytics, data interpretation, and automated decision-making ac...
Read more→Automated Eligibility Vertification
What is Eligibility Verification? Eligibility Verification is the process of confirming a patient's active insurance coverage for the specific date of service, determining if the plan is active, and confirming the services (benefits) covered and estimated costs. This is a critica...
Read more→Charge Capture
What is Charge Capture? Charge Capture is the process of translating every billable service and supply rendered to a patient into a documented charge on the organization's financial record. It is the foundation of the mid-cycle, ensuring that the services documented in the EHR/EM...
Read more→Claims Adjudication
What is Claims Adjudication? Claims Adjudication is the process by which a payer (insurance company) formally reviews a submitted healthcare claim to determine the amount, if any, they will pay the provider for the services rendered. It is the core decision-making stage where the...
Read more→Claims Submission Software
What is Claims Submission Software? Claims Submission Software is a specialized application that formats, organizes, and securely transmits healthcare claims (837 EDI files) from the healthcare provider to the payer or to an intermediary Financial Clearinghouse. In the context of...
Read more→Clean Claim Rate (CCR)
What is Clean Claim Rate (CCR)? The Clean Claim Rate (CCR) is a vital Key Performance Indicator (KPI) that measures the percentage of claims submitted to a payer that are processed and paid upon the first submission, without requiring any manual intervention, correction, or appea...
Read more→Clinical Documentation Integrity (CDI)
What is Clinical Documentation Integrity (CDI)? Clinical Documentation Integrity (CDI) is the process of ensuring that the patient's medical record (EHR/EMR) accurately reflects the patient's severity of illness, intensity of services, and the specific reason for the encounter. C...
Read more→Coordination of Benefits (COB)
What is Coordination of Benefits (COB)? Coordination of Benefits (COB) is a process used by health insurance payers to determine which plan is the primary payer and which plans are secondary (or tertiary) when a patient is covered by two or more active health insurance policies. ...
Read more→Denial Management
What is Denial Management? Denial Management is the strategic and operational process of identifying, tracking, categorizing, correcting, and appealing claims that have been formally rejected or denied by a payer during Claims Adjudication. Effective denial management focuses on ...
Read more→Electronic Data Interchange (EDI)
What is Electronic Data Interchange (EDI)? Electronic Data Interchange (EDI) is the standardized, secure electronic transmission of business documents—specifically healthcare claims and remittances—between providers, payers, and financial clearinghouses. In RCM, EDI relies on man...
Read more→Machine Learning (ML) in Billing
What is Machine Learning (ML) in Billing? Machine Learning (ML) in healthcare billing is a subset of Artificial Intelligence (AI) where computer algorithms are trained on vast amounts of historical claims data, denial patterns, and remittance information to recognize complex rela...
Read more→Predictive Analytics for Denials
What is Predictive Analytics for Denials? Predictive Analytics for Denials is the application of advanced Artificial Intelligence (AI) and Machine Learning (ML) to analyze historical claims, payer behavior, and provider documentation patterns to forecast the probability that a sp...
Read more→RCM Automation
What is Revenue Cycle Management (RCM) Automation? Revenue Cycle Management (RCM) Automation involves using advanced technologies like Artificial Intelligence (AI), Machine Learning (ML), and Robotic Process Automation (RPA) to streamline, optimize, and execute the financial and ...
Read more→Revenue Cycle Management (RCM)
What is Revenue Cycle Management (RCM)? Revenue Cycle Management (RCM) is the entire end-to-end financial workflow that tracks a patient encounter from scheduling, payer authorization, and through to payment. It is the financial and revenue collection engine of a healthcare organ...
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