Every term, transaction, and failure point that moves money through a US healthcare claim — explained without the fog.
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The vocabulary the whole cycle runs on.
Revenue cycle management (RCM)
The end-to-end financial process of a patient encounter — scheduling and registration, eligibility, coding, claim submission, payment, and collection of any patient balance. Every dollar earned in care is either captured or lost across these steps.
Clean claim rate
The share of claims that adjudicate correctly on first submission with no edits or rejections. It's the highest-leverage metric in RCM: rework is where cost and delay compound.
Days in A/R
Average days to collect after billing. Rising days-in-A/R is an early warning that claims are aging, denials are climbing, or follow-up has stalled.
Charge capture
The process of recording every billable service delivered so nothing performed goes unbilled. Missed charges are silent revenue leakage that never even reaches a claim.
Everything that has to be right before care is delivered.
Eligibility verification (270 / 271)
The electronic coverage check: the provider sends a 270 inquiry, the payer returns a 271 with active coverage and benefits. Run before the visit, it stops claims from billing into lapsed or wrong policies.
Prior authorization
A payer's advance approval for certain services or drugs. It fails when care precedes the auth, or when the auth on file doesn't match what was actually performed — both invite denials.
Coordination of benefits (COB)
The rules that decide which payer is primary when a patient has more than one plan. Getting COB order wrong is a common, fully preventable denial.
Turning care delivered into codes a payer will honor.
ICD-10-CM
The diagnosis code set — what is wrong with the patient. Maintained in the US by the CDC's NCHS and CMS and updated annually, so coding against the current release matters.
CPT / HCPCS
The procedure and service code sets — what was done. CPT is owned and maintained by the American Medical Association; HCPCS Level II covers items and services CPT doesn't.
Medical necessity
The requirement that a service was appropriate for the diagnosis. Payers link procedures to acceptable diagnoses; if the codes don't support each other under policy, the claim is denied even when the care was correct.
Modifiers
Two-character additions to a CPT/HCPCS code that clarify what happened — a bilateral procedure, a distinct service, a reduced service. Wrong or missing modifiers are a frequent denial and audit trigger.
How claims move, and how payers answer.
837 claim
The standard electronic claim format — 837P professional, 837I institutional. It carries claims from provider to clearinghouse to payer, replacing paper CMS-1500 and UB-04 forms.
835 / ERA
The electronic remittance advice: the payer's line-by-line explanation of what was paid, adjusted, or denied. Posting and reconciling it is how underpayments and partial denials get caught.
Clearinghouse
The intermediary that validates, formats, and routes claims between providers and payers, catching format errors before they reach the payer as rejections.
Timely filing limit
The deadline to get a claim to the payer after service. It varies by payer and contract; missing it is an outright, near-unappealable denial — pure preventable loss.
Preventing the loss, and recovering what still slips.
Rejection vs. denial
A rejection fails an edit before adjudication and can be corrected and resubmitted. A denial is a payer decision after adjudication and requires an appeal. Treating one as the other wastes time.
CARC / RARC codes
Claim Adjustment Reason Codes and Remittance Advice Remark Codes explain, in standardized form, why a line was adjusted or denied. Reading them correctly turns a denial into a specific, appealable reason.
Denial management
The discipline of preventing denials upstream and working the ones that land — documentation, appeals, and feeding the root cause back to whatever step let them through.
DNFB (discharged, not final billed)
Accounts where the patient is discharged but the claim hasn't gone out, usually waiting on coding or documentation. DNFB is revenue earned but frozen — a common hospital leak.
How data is handled, and how GetMax fits in.
HIPAA-aligned handling
GetMax follows HIPAA-aligned handling of protected health information across its platform and workflows. We say 'aligned' rather than 'certified' — the honest framing for a pre-traction company — and will walk your team through the specifics.
AI + specialists model
Automation runs the high-volume, rule-bound work; credentialed specialists take appeals and edge cases. The intent is accuracy at volume without turning the cycle into a black box.
One connected cycle
Every stage on one platform sharing one record, so a coding decision is visible to A/R and a denial informs the next claim — instead of eight hand-offs between disconnected tools.