Revenue cycle, answered.

Revenue cycle management is the full financial process of a patient encounter — from scheduling and insurance verification, through coding and claim submission, to payment posting and collection of any patient balance. It covers every step between a patient booking care and the provider being fully paid for it.

In order: patient access (scheduling, registration, eligibility), prior authorization where required, charge capture and medical coding, claim submission, payer adjudication, payment posting and reconciliation, denial management and appeals, and finally accounts-receivable follow-up and patient collections. A leak at any stage costs money downstream.

Days in accounts receivable measures the average number of days it takes to collect payment after a service is billed. Lower is better — rising days-in-A/R signals claims are aging, denials are stacking up, or follow-up has stalled, all of which tie up cash the practice has already earned.

A clean claim is one that passes payer edits and adjudicates on the first submission with no errors, missing data, or rejections. First-pass clean claims are the single biggest lever in the revenue cycle: every claim that has to be reworked adds cost and delays payment.

Because coverage changes constantly — plans lapse, deductibles reset, benefits differ by service. Verifying active coverage and benefits before care is delivered stops claims from billing into a dead or wrong policy, which is one of the most common and most preventable causes of denials.

They're the standard electronic eligibility exchange. The 270 is the inquiry a provider sends to a payer asking about a patient's coverage and benefits; the 271 is the payer's response. Running these in real time lets front-desk and billing teams confirm coverage instantly instead of calling payers.

Prior authorization is a payer's advance approval for certain services, drugs, or procedures. It breaks when care is delivered before the auth is secured, or when the auth on file doesn't exactly match what was performed — both give the payer grounds to deny, often after the fact.

ICD-10-CM codes describe the diagnosis — what is wrong with the patient. CPT codes (and HCPCS) describe the procedure or service performed. A claim generally needs both, and they must support each other: the diagnosis has to justify the medical necessity of the procedure billed.

ICD-10-CM is maintained in the US by the CDC's National Center for Health Statistics and CMS, and updated annually. CPT is owned and maintained by the American Medical Association. Because both change every year, coding against the current, correct code set is a moving target that catches teams working from memory.

Medical necessity is the requirement that a service was reasonable and appropriate for the patient's diagnosis. Payers enforce it through coverage rules that link specific procedures to acceptable diagnoses. If the diagnosis coded doesn't support the procedure under the payer's policy, the claim is denied regardless of whether the care was correct.

AI applies and checks codes against payer rules as they're assigned, and credentialed coders handle the judgment calls and edge cases. The aim is accuracy at volume — catching mismatches before submission rather than reworking denials after.

The 837 is the standard electronic format for submitting a healthcare claim to a payer — professional (837P), institutional (837I), or dental. It's how claims move electronically from provider to clearinghouse to payer, replacing paper CMS-1500 and UB-04 forms in most workflows.

The 835, or electronic remittance advice, is the payer's electronic explanation of what it paid, adjusted, or denied on a claim. Posting and reconciling the 835 against the original claim is how a practice catches underpayments and partial denials that would otherwise slip through.

It's the deadline by which a claim must reach the payer after the date of service. Limits vary by payer and contract — miss it and the claim is denied outright, with little recourse. Timely filing denials are pure preventable loss, which is why aging claims need to be worked before the clock runs out.

A rejection happens before adjudication — the claim fails a format or data edit at the clearinghouse or payer front door and never enters the payer's system, so it can be corrected and resubmitted. A denial happens after adjudication — the payer processed the claim and decided not to pay, which requires an appeal rather than a simple fix.

The recurring culprits are eligibility and coverage issues, missing or mismatched prior authorization, coding and medical-necessity problems, missing information, and timely-filing misses. Most are preventable upstream — which is why prevention beats appeal.

Two halves: preventing denials by catching root causes before submission, and working the ones that land — reading the remark codes, gathering documentation, and appealing fast before deadlines pass. The pattern in the denials also feeds back to fix whatever upstream step let them through.

Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC) are the standardized codes on a remittance that explain why a payer adjusted or denied a line. Reading them correctly is what turns a denial from a dead end into a specific, appealable reason.

GetMax is AI-native: automation runs the high-volume, rule-bound work — eligibility, coding checks, claim scrubbing, status follow-up — while credentialed specialists take the appeals and edge cases that need human judgment. It's built as one connected cycle rather than eight hand-offs between disconnected tools.

It's designed to work as an extension of your team, not a black box that replaces it. The practice keeps visibility into where every claim sits and why each decision was made. How deeply GetMax plugs in depends on what you need — from specific stages to the full cycle.

GetMax follows HIPAA-aligned handling of protected health information across its platform and workflows. We deliberately say 'aligned' rather than 'certified' — the honest framing for where we are — and we're glad to walk your team through exactly how data is handled.

The platform is built to work across the EHR and practice-management systems providers already run, connecting through standard healthcare data exchange rather than forcing a rip-and-replace. Tell us what you're on and we'll show you how it fits.