Revenue Cycle Glossary · Health Tech

270/271: the X12 eligibility inquiry and response: is a member covered, and what does the plan pay for a service type (Eligibility & Benefits).
276/277: the X12 claim status inquiry and response, with category codes for received, pending, information requested and finalized (Denials, Appeals & Claim Status).
277CA: the claim acknowledgment saying a clearinghouse or payer accepted a claim into adjudication or rejected it (Claims).
278: the X12 prior authorization request and response, HIPAA's adopted standard, now giving way to FHIR APIs (Prior Authorization).
835 (ERA, electronic remittance advice): the X12 payment and remittance advice: what a payer paid, adjusted and assigned to the patient, line by line (Remittance & Posting).
837P, 837I, 837D: the X12 professional, institutional and dental claims, version 5010 under HIPAA (Claims).
999: the implementation acknowledgment saying an X12 file was or wasn't syntactically valid (Claims).
ABN (advance beneficiary notice, CMS-R-131): the notice a traditional Medicare patient signs before a service Medicare is expected to deny, so the provider may bill them (Coding, Documentation & Compliance).
ACO (accountable care organization): providers jointly accountable for the cost and quality of an assigned Medicare population, sharing in savings (Value-Based Care & Quality).
Advanced APM (alternative payment model): a risk-bearing payment model whose qualifying participants are paid from a higher conversion factor from 2026 (Value-Based Care & Quality).
Anti-Kickback Statute (AKS): the federal crime of paying or receiving anything of value for referrals of federal program business, with regulatory safe harbors (Coding, Documentation & Compliance).
Attribution: a program's assignment of patients to the clinician or organization accountable for them, per period (Value-Based Care & Quality).
CARC (claim adjustment reason code): the code saying why a dollar on a remittance wasn't paid, such as 45 for a charge over the fee schedule (Remittance & Posting).
CCD+: the Nacha corporate credit with one addenda record that HIPAA requires for health care EFT, carrying the 835's trace number (Remittance & Posting).
CDI (clinical documentation integrity): reviewing records and sending non-leading queries so documentation supports accurate codes (Coding, Documentation & Compliance).
Clean claim rate: claims that pass edits with no manual intervention over claims accepted into the claims tool, in HFMA's definition (The Revenue Cycle).
COB (coordination of benefits): the rules deciding which of a patient's plans pays first, including the birthday rule for children (Eligibility & Benefits).
CRD, DTR, PAS (Da Vinci): HL7 FHIR guides for discovering whether authorization is required, completing the payer's documentation, and submitting the request (Prior Authorization).
Crossover: Medicare forwarding a processed claim to a supplemental payer or Medicaid automatically (Remittance & Posting).
Days in A/R: net accounts receivable over average daily net patient service revenue; how long money sits between service and cash (The Revenue Cycle).
Denial: an adjudicated claim line the payer refused to pay, appealed or corrected; distinct from a rejection (Denials, Appeals & Claim Status).
Downgrade (alternate benefit): a dental plan paying for a procedure at the rate of a cheaper alternative, such as a composite filling at the amalgam rate (Eligibility & Benefits).
E/M (evaluation and management): visit codes whose level is chosen by medical decision making or total time since 2021 (Coding, Documentation & Compliance).
eCQM (electronic clinical quality measure): a measure specified to be computed from structured EHR data, published on the eCQI Resource Center (Value-Based Care & Quality).
False Claims Act: federal liability, per claim and trebled, for knowingly submitting or causing false claims, mostly enforced through whistleblower suits (Coding, Documentation & Compliance).
Frequency limitation: a dental or medical plan's cap on how often a procedure is covered, per year, per period or per tooth (Eligibility & Benefits).
Gold carding: a state-law exemption from prior authorization for a provider with a high approval rate for a service (Prior Authorization).
Good faith estimate: the itemized estimate the No Surprises Act requires for uninsured and self-pay patients within 1 or 3 business days (Patient Statements, Estimates & Collections).
Group code: the remittance code saying who bears an adjustment: CO contractual, PR patient, OA other, PI payer-initiated (Remittance & Posting).
HCC (hierarchical condition category): a group of diagnoses that raises a Medicare Advantage risk score (Value-Based Care & Quality).
HEDIS: NCQA's measure set for health plans, more than 90 measures that commercial and MA contracts pay practices on (Value-Based Care & Quality).
LCD (local coverage determination): a Medicare contractor's coverage policy for its jurisdiction where no national policy exists (Coding, Documentation & Compliance).
Medical debt reporting laws: state laws barring or limiting credit reporting of medical debt, in 15 states and DC as of September 2026 (Patient Statements, Estimates & Collections).
MIPS (Merit-based Incentive Payment System): Medicare's scoring of clinicians on quality, cost, improvement activities and interoperability, adjusting Part B payments (Value-Based Care & Quality).
Modifier: a two-character code on a claim line changing what a procedure code means, such as 25 or 59 (Claims).
MSSP (Medicare Shared Savings Program): Medicare's permanent ACO program (Value-Based Care & Quality).
MUE (medically unlikely edit): CMS's cap on the units of a code reported for one patient on one day (Claims).
NCCI (National Correct Coding Initiative): CMS's quarterly code pair (PTP) and unit (MUE) edits (Claims).
NCD (national coverage determination): CMS's nationwide Medicare coverage policy for a service (Coding, Documentation & Compliance).
Operating rules (CAQH CORE): HIPAA-adopted rules for how parties behave around the standard transactions: real-time eligibility, consistent codes, EFT and ERA matching (The Revenue Cycle).
Patient control number: the practice's own claim identifier (CLM01), echoed on every acknowledgment and remittance (Claims).
Payer ID: a payer's routing identifier at a particular clearinghouse; it differs between clearinghouses (Clearinghouses).
Predetermination: a dental pre-treatment estimate from the payer; an estimate, not a permission (Claims).
Prior authorization: the payer's permission, before a service, that it will consider the service necessary and covered (Prior Authorization).
RAC (recovery audit contractor): Medicare's post-payment auditors, contracted by region (Denials, Appeals & Claim Status).
RADV (risk adjustment data validation): CMS's audit of the diagnoses behind Medicare Advantage payments (Value-Based Care & Quality).
RARC (remittance advice remark code): a code adding detail to an adjustment, such as what was missing (Remittance & Posting).
Reassociation: matching an EFT deposit to its 835 by the TRN trace number and amount (Remittance & Posting).
Recoupment: a payer taking back an overpayment on an older claim by reducing a later payment (Remittance & Posting).
Rejection: a claim refused before adjudication, by syntax, clearinghouse or payer edits; fixed and resent, not appealed (Claims).
Revenue cycle: the chain from registration and eligibility through coding, claims, remittance, denials and patient collection (The Revenue Cycle).
Service type code: the X12 code naming what an eligibility inquiry asks about, such as 30 for plan coverage or 35 for dental care (Eligibility & Benefits).
Stark (physician self-referral law): the strict liability ban on physicians referring Medicare patients to entities they have financial relationships with, unless an exception applies (Coding, Documentation & Compliance).
Timely filing: a payer's deadline from the date of service to receive a claim; one calendar year for Medicare (Claims).
Upcoding: billing a higher-paying code, or adding diagnoses, beyond what the documentation supports (Coding, Documentation & Compliance).
Virtual card payment: a payer paying a provider with a single-use card the practice runs at its own processing cost; providers may insist on EFT instead (Remittance & Posting).

270/271: the X12 eligibility inquiry and response: is a member covered, and what does the plan pay for a service type (Eligibility & Benefits).
276/277: the X12 claim status inquiry and response, with category codes for received, pending, information requested and finalized (Denials, Appeals & Claim Status).
277CA: the claim acknowledgment saying a clearinghouse or payer accepted a claim into adjudication or rejected it (Claims).
278: the X12 prior authorization request and response, HIPAA's adopted standard, now giving way to FHIR APIs (Prior Authorization).
835 (ERA, electronic remittance advice): the X12 payment and remittance advice: what a payer paid, adjusted and assigned to the patient, line by line (Remittance & Posting).
837P, 837I, 837D: the X12 professional, institutional and dental claims, version 5010 under HIPAA (Claims).
999: the implementation acknowledgment saying an X12 file was or wasn't syntactically valid (Claims).
ABN (advance beneficiary notice, CMS-R-131): the notice a traditional Medicare patient signs before a service Medicare is expected to deny, so the provider may bill them (Coding, Documentation & Compliance).
ACO (accountable care organization): providers jointly accountable for the cost and quality of an assigned Medicare population, sharing in savings (Value-Based Care & Quality).
Advanced APM (alternative payment model): a risk-bearing payment model whose qualifying participants are paid from a higher conversion factor from 2026 (Value-Based Care & Quality).
Anti-Kickback Statute (AKS): the federal crime of paying or receiving anything of value for referrals of federal program business, with regulatory safe harbors (Coding, Documentation & Compliance).
Attribution: a program's assignment of patients to the clinician or organization accountable for them, per period (Value-Based Care & Quality).
CARC (claim adjustment reason code): the code saying why a dollar on a remittance wasn't paid, such as 45 for a charge over the fee schedule (Remittance & Posting).
CCD+: the Nacha corporate credit with one addenda record that HIPAA requires for health care EFT, carrying the 835's trace number (Remittance & Posting).
CDI (clinical documentation integrity): reviewing records and sending non-leading queries so documentation supports accurate codes (Coding, Documentation & Compliance).
Clean claim rate: claims that pass edits with no manual intervention over claims accepted into the claims tool, in HFMA's definition (The Revenue Cycle).
COB (coordination of benefits): the rules deciding which of a patient's plans pays first, including the birthday rule for children (Eligibility & Benefits).
CRD, DTR, PAS (Da Vinci): HL7 FHIR guides for discovering whether authorization is required, completing the payer's documentation, and submitting the request (Prior Authorization).
Crossover: Medicare forwarding a processed claim to a supplemental payer or Medicaid automatically (Remittance & Posting).
Days in A/R: net accounts receivable over average daily net patient service revenue; how long money sits between service and cash (The Revenue Cycle).
Denial: an adjudicated claim line the payer refused to pay, appealed or corrected; distinct from a rejection (Denials, Appeals & Claim Status).
Downgrade (alternate benefit): a dental plan paying for a procedure at the rate of a cheaper alternative, such as a composite filling at the amalgam rate (Eligibility & Benefits).
E/M (evaluation and management): visit codes whose level is chosen by medical decision making or total time since 2021 (Coding, Documentation & Compliance).
eCQM (electronic clinical quality measure): a measure specified to be computed from structured EHR data, published on the eCQI Resource Center (Value-Based Care & Quality).
False Claims Act: federal liability, per claim and trebled, for knowingly submitting or causing false claims, mostly enforced through whistleblower suits (Coding, Documentation & Compliance).
Frequency limitation: a dental or medical plan's cap on how often a procedure is covered, per year, per period or per tooth (Eligibility & Benefits).
Gold carding: a state-law exemption from prior authorization for a provider with a high approval rate for a service (Prior Authorization).
Good faith estimate: the itemized estimate the No Surprises Act requires for uninsured and self-pay patients within 1 or 3 business days (Patient Statements, Estimates & Collections).
Group code: the remittance code saying who bears an adjustment: CO contractual, PR patient, OA other, PI payer-initiated (Remittance & Posting).
HCC (hierarchical condition category): a group of diagnoses that raises a Medicare Advantage risk score (Value-Based Care & Quality).
HEDIS: NCQA's measure set for health plans, more than 90 measures that commercial and MA contracts pay practices on (Value-Based Care & Quality).
LCD (local coverage determination): a Medicare contractor's coverage policy for its jurisdiction where no national policy exists (Coding, Documentation & Compliance).
Medical debt reporting laws: state laws barring or limiting credit reporting of medical debt, in 15 states and DC as of September 2026 (Patient Statements, Estimates & Collections).
MIPS (Merit-based Incentive Payment System): Medicare's scoring of clinicians on quality, cost, improvement activities and interoperability, adjusting Part B payments (Value-Based Care & Quality).
Modifier: a two-character code on a claim line changing what a procedure code means, such as 25 or 59 (Claims).
MSSP (Medicare Shared Savings Program): Medicare's permanent ACO program (Value-Based Care & Quality).
MUE (medically unlikely edit): CMS's cap on the units of a code reported for one patient on one day (Claims).
NCCI (National Correct Coding Initiative): CMS's quarterly code pair (PTP) and unit (MUE) edits (Claims).
NCD (national coverage determination): CMS's nationwide Medicare coverage policy for a service (Coding, Documentation & Compliance).
Operating rules (CAQH CORE): HIPAA-adopted rules for how parties behave around the standard transactions: real-time eligibility, consistent codes, EFT and ERA matching (The Revenue Cycle).
Patient control number: the practice's own claim identifier (CLM01), echoed on every acknowledgment and remittance (Claims).
Payer ID: a payer's routing identifier at a particular clearinghouse; it differs between clearinghouses (Clearinghouses).
Predetermination: a dental pre-treatment estimate from the payer; an estimate, not a permission (Claims).
Prior authorization: the payer's permission, before a service, that it will consider the service necessary and covered (Prior Authorization).
RAC (recovery audit contractor): Medicare's post-payment auditors, contracted by region (Denials, Appeals & Claim Status).
RADV (risk adjustment data validation): CMS's audit of the diagnoses behind Medicare Advantage payments (Value-Based Care & Quality).
RARC (remittance advice remark code): a code adding detail to an adjustment, such as what was missing (Remittance & Posting).
Reassociation: matching an EFT deposit to its 835 by the TRN trace number and amount (Remittance & Posting).
Recoupment: a payer taking back an overpayment on an older claim by reducing a later payment (Remittance & Posting).
Rejection: a claim refused before adjudication, by syntax, clearinghouse or payer edits; fixed and resent, not appealed (Claims).
Revenue cycle: the chain from registration and eligibility through coding, claims, remittance, denials and patient collection (The Revenue Cycle).
Service type code: the X12 code naming what an eligibility inquiry asks about, such as 30 for plan coverage or 35 for dental care (Eligibility & Benefits).
Stark (physician self-referral law): the strict liability ban on physicians referring Medicare patients to entities they have financial relationships with, unless an exception applies (Coding, Documentation & Compliance).
Timely filing: a payer's deadline from the date of service to receive a claim; one calendar year for Medicare (Claims).
Upcoding: billing a higher-paying code, or adding diagnoses, beyond what the documentation supports (Coding, Documentation & Compliance).
Virtual card payment: a payer paying a provider with a single-use card the practice runs at its own processing cost; providers may insist on EFT instead (Remittance & Posting).