Common R.C.M Terms and Phrases
These are words and phrases that occur frequently in RCM.
- Acknowledged
- Ajudication
- Authorization
- Billed Amount
- Billing
- Billing Provider
- Carrier
- Claims
- Claim Number
- CMS 1500 Form
- Date of Service (D.O.S)
- Denied
- Denial Code
- Denial Reason
- Diagnosis Code
- Evidence of Benefits (E.O.B)
- Eligibility
- EVV
- Finalized
- Home Health
- Inpatient
- In Process/Pending
- LVN-: Licensed Vocational Nurse
- Modifier
- Medicaid
- Medicare
- Member ID
- Mental Health
- NPI
- Outpatient
- Pay period
- Paid Amount
- Patient Account Number
- Place of Service
- Policy Group
- Procedure/Service Code
- Processed Date
- Program
- Reconciliation
- Resubmission
- Remittance Advice
- RN-: Registered Nurse
- Service Code
- Status
- Taxonomy
- Tax ID
- Units
- 270
- 271
- 835
- 837
- 999
Status update given by insurance carriers, indicating that they have recieved, and are working on a claim.
The full processing of claims done by carriers in order to come up with a resolution to the claim.
A verification process to understand the extent of coverage.
Reimbursement requested by a service provider for services rendered.
Process of requesting reimbursements for services rendered.
The party that has the authority to act on the behalf of the service provider.
This is essentially an insurance company. In this particular context, a health insurance company.
A formal demand for reimbursements.
A unique identifier for claims.
The standard claim form used to bill Medicare carriers and some Medicaid State Agencies.
The date a particular service was rendered.
Refusal to make reimbursements for claims.
A code that accompanies denials to to identify the root cause of the denial.
The detaialing of the grounds upon which a claim will not be reimbursed.
A standardized code to identify the ailment a patient was diagnosed with.
Document detailing the outcome of an adjudication process.
Process to ascertain the coverage of a client.
Method of verification of home healthcare visits to reduce fraudulently documented home visits and ensure patients are not uncared for.
Claims that have reached the end of thier adjudication cycle.
A type of health care service provided in the patients residence.
Any service or treatment that requires hospitalization.
A claim status that implies the claim is still undergoing adjuducation.
Code used to indicate an alteration in a service or procedure due to specific circumstances, without changing the original definition or code.
Health insurance provided by State governments.
Health insurance provided by the U.S Federal government.
A unique number that identifies clients as covered members of a particular carrier.
Cognitive, behavioral and emotional well being.
A unique 10 digit identification number issued to healthcare providers.
Any service or treatment that does not requires hospitalization.
Duration of time within which reimbursements will be made to service providers.
The exact sum paid as reimbursement .
Unique identification number used healthcare providers to track patient account.
Setting a service is provided.
Codes used to identify what was done to or given to a patient.
The date the decision of the adjudication process was reached.
The sorting of services according to service type and location.
Recording and posting of payments recieved to ensure accurate accounting and revenue tracking.
Submission of an already processed claims for review after necessary corrections have been made. There is an allowable period for resubmissions called the resubmission window.
File detailing reimbursements and denials.
A unique identifier for the type of service rendered.
The stage the claim is at in the adjudication process.
The classification and categorization of healthcare services and procedures for standardized billing and coding purposes.
Service providers Tax Identifiction numer.
A means to measure the number of occurrences or duration of a service rendered.
File requesting for the eligibility information of clients with Medicaid as their carrier.
File responding to the eligibility request (270) detailing the eligibility status of clients.
File detailing reimbursements and denials made.
File used to submit claims during billing. It is usually encrypted
Functional acknowledgement of the 837 file, stating if the file can be processed or not.
