Revenue Cycle Management Glossary

Glossary of revenue cycle management and medical billing terms used across BillingBench tools and the industry at large. Covers CARC and RARC denial codes, payer types, claim forms, regulatory terms, and standard RCM performance metrics with plain-language definitions.

Key claim terms: clean claim (a claim that contains all required information and has no defects or improprieties — the trigger for prompt pay statute timelines), CARC (Claim Adjustment Reason Code — explains why a claim was adjusted or denied in an 835 ERA), RARC (Remittance Advice Remark Code — provides supplemental explanation in an 835 ERA), EOB (Explanation of Benefits — payer's payment explanation sent to the member), ERA (Electronic Remittance Advice — the 835 transaction sent to the provider), EFT (Electronic Funds Transfer — direct deposit of claim payment), NPI (National Provider Identifier — 10-digit CMS-assigned provider identifier required on all HIPAA-covered claims).

Key regulatory terms: ERISA (Employee Retirement Income Security Act of 1974 — governs self-funded employer health plans; preempts state insurance law under §514(a)), ACA (Affordable Care Act — adds external review rights for non-grandfathered plans under §2719, internal appeal requirements under §2719), HIPAA (Health Insurance Portability and Accountability Act — governs PHI privacy, security, and electronic transaction standards including the 837P claim and 835 ERA), MHPAEA (Mental Health Parity and Addiction Equity Act — requires comparable benefit limits between mental health/substance use and medical/surgical benefits), LCD (Local Coverage Determination — MAC-issued coverage criteria for Medicare), NCD (National Coverage Determination — CMS-issued national coverage policy).

• Denial code lookup — CARC and RARC reference
• RCM benchmarks — metric definitions and targets
• 835 ERA reference — transaction format and segment definitions