# Revenue Cycle Glossary

> 56 terms from the Health Tech book's Revenue Cycle part, each defined in a line and linked to the chapter that explains it.

- **270/271:** the X12 eligibility inquiry and response: is a member covered, and what does the plan pay for a service type ([Eligibility & Benefits](https://www.syntaqx.com/books/health-tech/eligibility-and-benefits#the-270-and-271)).
- **276/277:** the X12 claim status inquiry and response, with category codes for received, pending, information requested and finalized ([Denials, Appeals & Claim Status](https://www.syntaqx.com/books/health-tech/denials-and-appeals#claim-status-276-and-277)).
- **277CA:** the claim acknowledgment saying a clearinghouse or payer accepted a claim into adjudication or rejected it ([Claims](https://www.syntaqx.com/books/health-tech/claims#submission-and-acknowledgments)).
- **278:** the X12 prior authorization request and response, HIPAA's adopted standard, now giving way to FHIR APIs ([Prior Authorization](https://www.syntaqx.com/books/health-tech/prior-authorization#the-278-and-the-fax)).
- **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](https://www.syntaqx.com/books/health-tech/remittance-and-payment-posting#the-835)).
- **837P, 837I, 837D:** the X12 professional, institutional and dental claims, version 5010 under HIPAA ([Claims](https://www.syntaqx.com/books/health-tech/claims#the-837-claim)).
- **999:** the implementation acknowledgment saying an X12 file was or wasn't syntactically valid ([Claims](https://www.syntaqx.com/books/health-tech/claims#submission-and-acknowledgments)).
- **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](https://www.syntaqx.com/books/health-tech/coding-and-documentation#medical-necessity-ncds-and-lcds)).
- **ACO (accountable care organization):** providers jointly accountable for the cost and quality of an assigned Medicare population, sharing in savings ([Value-Based Care & Quality](https://www.syntaqx.com/books/health-tech/value-based-care#acos-the-shared-savings-program-reach-and-lead)).
- **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](https://www.syntaqx.com/books/health-tech/value-based-care#alternative-payment-models)).
- **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](https://www.syntaqx.com/books/health-tech/coding-and-documentation#anti-kickback-and-stark-for-software)).
- **Attribution:** a program's assignment of patients to the clinician or organization accountable for them, per period ([Value-Based Care & Quality](https://www.syntaqx.com/books/health-tech/value-based-care#what-the-software-must-capture)).
- **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](https://www.syntaqx.com/books/health-tech/remittance-and-payment-posting#carc-rarc-and-group-codes)).
- **CCD+:** the Nacha corporate credit with one addenda record that HIPAA requires for health care EFT, carrying the 835's trace number ([Remittance & Posting](https://www.syntaqx.com/books/health-tech/remittance-and-payment-posting#eft-and-reassociation)).
- **CDI (clinical documentation integrity):** reviewing records and sending non-leading queries so documentation supports accurate codes ([Coding, Documentation & Compliance](https://www.syntaqx.com/books/health-tech/coding-and-documentation#documentation-integrity)).
- **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](https://www.syntaqx.com/books/health-tech/revenue-cycle#the-kpis)).
- **COB (coordination of benefits):** the rules deciding which of a patient's plans pays first, including the birthday rule for children ([Eligibility & Benefits](https://www.syntaqx.com/books/health-tech/eligibility-and-benefits#coordination-of-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](https://www.syntaqx.com/books/health-tech/prior-authorization#da-vinci-crd-dtr-and-pas)).
- **Crossover:** Medicare forwarding a processed claim to a supplemental payer or Medicaid automatically ([Remittance & Posting](https://www.syntaqx.com/books/health-tech/remittance-and-payment-posting#secondary-claims)).
- **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](https://www.syntaqx.com/books/health-tech/revenue-cycle#the-kpis)).
- **Denial:** an adjudicated claim line the payer refused to pay, appealed or corrected; distinct from a rejection ([Denials, Appeals & Claim Status](https://www.syntaqx.com/books/health-tech/denials-and-appeals#denial-categories)).
- **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](https://www.syntaqx.com/books/health-tech/eligibility-and-benefits#dental-benefits)).
- **E/M (evaluation and management):** visit codes whose level is chosen by medical decision making or total time since 2021 ([Coding, Documentation & Compliance](https://www.syntaqx.com/books/health-tech/coding-and-documentation#evaluation-and-management)).
- **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](https://www.syntaqx.com/books/health-tech/value-based-care#hedis-and-ecqms)).
- **False Claims Act:** federal liability, per claim and trebled, for knowingly submitting or causing false claims, mostly enforced through whistleblower suits ([Coding, Documentation & Compliance](https://www.syntaqx.com/books/health-tech/coding-and-documentation#the-false-claims-act)).
- **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](https://www.syntaqx.com/books/health-tech/eligibility-and-benefits#dental-benefits)).
- **Gold carding:** a state-law exemption from prior authorization for a provider with a high approval rate for a service ([Prior Authorization](https://www.syntaqx.com/books/health-tech/prior-authorization#industry-commitments-and-gold-carding)).
- **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](https://www.syntaqx.com/books/health-tech/patient-financial-experience#the-no-surprises-act)).
- **Group code:** the remittance code saying who bears an adjustment: CO contractual, PR patient, OA other, PI payer-initiated ([Remittance & Posting](https://www.syntaqx.com/books/health-tech/remittance-and-payment-posting#carc-rarc-and-group-codes)).
- **HCC (hierarchical condition category):** a group of diagnoses that raises a Medicare Advantage risk score ([Value-Based Care & Quality](https://www.syntaqx.com/books/health-tech/value-based-care#medicare-advantage-and-risk-adjustment)).
- **HEDIS:** NCQA's measure set for health plans, more than 90 measures that commercial and MA contracts pay practices on ([Value-Based Care & Quality](https://www.syntaqx.com/books/health-tech/value-based-care#hedis-and-ecqms)).
- **LCD (local coverage determination):** a Medicare contractor's coverage policy for its jurisdiction where no national policy exists ([Coding, Documentation & Compliance](https://www.syntaqx.com/books/health-tech/coding-and-documentation#medical-necessity-ncds-and-lcds)).
- **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](https://www.syntaqx.com/books/health-tech/patient-financial-experience#medical-debt-and-credit-reporting)).
- **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](https://www.syntaqx.com/books/health-tech/value-based-care#mips-and-the-quality-payment-program)).
- **Modifier:** a two-character code on a claim line changing what a procedure code means, such as 25 or 59 ([Claims](https://www.syntaqx.com/books/health-tech/claims#modifiers)).
- **MSSP (Medicare Shared Savings Program):** Medicare's permanent ACO program ([Value-Based Care & Quality](https://www.syntaqx.com/books/health-tech/value-based-care#acos-the-shared-savings-program-reach-and-lead)).
- **MUE (medically unlikely edit):** CMS's cap on the units of a code reported for one patient on one day ([Claims](https://www.syntaqx.com/books/health-tech/claims#scrubbing-and-edits)).
- **NCCI (National Correct Coding Initiative):** CMS's quarterly code pair (PTP) and unit (MUE) edits ([Claims](https://www.syntaqx.com/books/health-tech/claims#scrubbing-and-edits)).
- **NCD (national coverage determination):** CMS's nationwide Medicare coverage policy for a service ([Coding, Documentation & Compliance](https://www.syntaqx.com/books/health-tech/coding-and-documentation#medical-necessity-ncds-and-lcds)).
- **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](https://www.syntaqx.com/books/health-tech/revenue-cycle#operating-rules-and-connectivity)).
- **Patient control number:** the practice's own claim identifier (CLM01), echoed on every acknowledgment and remittance ([Claims](https://www.syntaqx.com/books/health-tech/claims#from-charges-to-a-claim)).
- **Payer ID:** a payer's routing identifier at a particular clearinghouse; it differs between clearinghouses ([Clearinghouses](https://www.syntaqx.com/books/health-tech/clearinghouses#payer-ids-and-connectivity)).
- **Predetermination:** a dental pre-treatment estimate from the payer; an estimate, not a permission ([Claims](https://www.syntaqx.com/books/health-tech/claims#dental-claims)).
- **Prior authorization:** the payer's permission, before a service, that it will consider the service necessary and covered ([Prior Authorization](https://www.syntaqx.com/books/health-tech/prior-authorization#when-authorization-is-required)).
- **RAC (recovery audit contractor):** Medicare's post-payment auditors, contracted by region ([Denials, Appeals & Claim Status](https://www.syntaqx.com/books/health-tech/denials-and-appeals#audits-and-recoupments)).
- **RADV (risk adjustment data validation):** CMS's audit of the diagnoses behind Medicare Advantage payments ([Value-Based Care & Quality](https://www.syntaqx.com/books/health-tech/value-based-care#medicare-advantage-and-risk-adjustment)).
- **RARC (remittance advice remark code):** a code adding detail to an adjustment, such as what was missing ([Remittance & Posting](https://www.syntaqx.com/books/health-tech/remittance-and-payment-posting#carc-rarc-and-group-codes)).
- **Reassociation:** matching an EFT deposit to its 835 by the TRN trace number and amount ([Remittance & Posting](https://www.syntaqx.com/books/health-tech/remittance-and-payment-posting#eft-and-reassociation)).
- **Recoupment:** a payer taking back an overpayment on an older claim by reducing a later payment ([Remittance & Posting](https://www.syntaqx.com/books/health-tech/remittance-and-payment-posting#provider-level-adjustments-and-recoupments)).
- **Rejection:** a claim refused before adjudication, by syntax, clearinghouse or payer edits; fixed and resent, not appealed ([Claims](https://www.syntaqx.com/books/health-tech/claims#submission-and-acknowledgments)).
- **Revenue cycle:** the chain from registration and eligibility through coding, claims, remittance, denials and patient collection ([The Revenue Cycle](https://www.syntaqx.com/books/health-tech/revenue-cycle#the-stages)).
- **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](https://www.syntaqx.com/books/health-tech/eligibility-and-benefits#service-type-codes)).
- **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](https://www.syntaqx.com/books/health-tech/coding-and-documentation#anti-kickback-and-stark-for-software)).
- **Timely filing:** a payer's deadline from the date of service to receive a claim; one calendar year for Medicare ([Claims](https://www.syntaqx.com/books/health-tech/claims#timely-filing)).
- **Upcoding:** billing a higher-paying code, or adding diagnoses, beyond what the documentation supports ([Coding, Documentation & Compliance](https://www.syntaqx.com/books/health-tech/coding-and-documentation#the-false-claims-act)).
- **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](https://www.syntaqx.com/books/health-tech/remittance-and-payment-posting#virtual-card-payments)).

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