Billing, Claims & RCM Glossary

Build the charge from source evidence

Charge capture converts a completed service and its supporting evidence into a proposed billable charge. The source should identify the person, actual service date and time, location, rendering professional, service, units or time, authorship, and signatures when required.

A qualified coding or billing reviewer applies the current code set, payer source, authorization, provider configuration, and documented service. The CPT family pages cover 97151, 97153, 97154, 97155, 97156, 97157, and 97158.

These identifiers do not establish provider eligibility, coverage, authorization, time support, units, clean-claim status, or payment by themselves. CPT content is proprietary. The AMA licensing FAQ explains licensing and copyright boundaries; licensed current materials and payer rules govern code use.

The CMS Medicaid NCCI FAQ concerns correct-coding edits, rather than coverage, medical necessity, prior authorization, or utilization guidance. Its Medicaid scope should not be generalized to every payer route.

Create and transmit the professional claim

The CMS-1500 is a paper professional claim form. An 837P transaction is the electronic professional healthcare claim transaction. CMS's professional claim page distinguishes the Medicare paper and electronic routes.

A clearinghouse can translate, validate, route, or report on transactions between a practice and payer. Its acceptance means only what the named artifact and trading-partner arrangement define.

Track the sender, receiver, file, transaction, claim, service-line, control number, time, artifact, and business meaning. An interchange acknowledgment, 999 transaction-set acknowledgment, proprietary clearinghouse report, and 277CA claim acknowledgment represent different layers.

CMS's March 2026 Medicare claim-status guide illustrates a Medicare route with 999 and 277CA acknowledgments and later claim-status tools. Other payers and clearinghouses can use different artifacts or proprietary reports.

Separate adjudication, remittance, and money

An 835 transaction carries healthcare claim-payment and adjustment information. An electronic remittance advice explains adjudication results and adjustments, commonly through an 835. An electronic funds transfer moves money.

CMS's ERA and EFT page distinguishes remittance information from fund movement. A practice should match the deposit to the remittance and original claims.

Payment posting records payer and patient financial activity against the correct claim, service line, balance, adjustment, and deposit. It should preserve the original remittance, posting rule, exception, correction, and reviewer.

Accounts receivable is money recorded as owed for services, subject to the practice's accounting and payer context. Aging begins from a defined event, such as claim submission or responsibility assignment. Mixes of unbilled work, rejected claims, pending adjudication, denials, patient balances, credits, and recoupments need separate queues.

Correct through the payer's actual route

A corrected claim changes a previously submitted claim through a permitted payer route. A void claim requests cancellation of a prior claim or adjudication under the applicable route.

A claim frequency code signals original, replacement, void, or another claim intent in the format and route that uses it. Paper CMS-1500 Item 22 instructions and electronic 837P companion-guide rules can differ. Verify the payer, product, format, route, status, and current source.

For an 837 replacement or void, use the verified payer claim control number and exact payer workflow. A practice account number, clearinghouse tracking number, batch ID, or authorization number is a different identifier. When the original remains pending, confirm whether the payer requires a status hold, portal action, or another path.

A clinician makes any permitted record correction under the documentation policy, preserving original content, author, date and time, and reason. Billing then selects the claim action from verified source evidence. Never rewrite clinical content to force a claim through an edit.

Measure a locked claim cohort

Suppose a fictional practice prepares 24 claims whose first-submission review date has passed. Local validation holds three, so 21 of 24, or 87.5%, transmit. A claim-level clearinghouse report forwards 20 and rejects one, making route yield 20 of 21, or 95.2%.

The payer's claim-level acknowledgment accepts 18 of those 20 for adjudication. Payer-intake yield is 18 of 20, or 90%, and original-worklist-to-payer-intake yield is 18 of 24, or 75%. The six claims outside payer intake remain visible: three local holds, one clearinghouse rejection, and two payer rejections.

Use a payer-specific maturity window for adjudication, denial, payment, and appeal measures. Keep claims that have not matured out of an adjudication denominator, then report them separately by count and age. Preserve claim and service-line units instead of mixing them in one rate.

Run one source-to-cash control table

For each claim, retain:

• source-record and authorization evidence
• code-set, payer-rule, provider, location, time, and unit decision
• transmission file, route, acknowledgments, and status checks
• adjudication, ERA or 835, EFT, posting, and reconciliation
• correction, void, appeal, refund, recoupment, and final disposition

Give every exception a current state, source, owner, next action, obligation date, evidence, and closure test. A clean work queue keeps clinical authorship, coding judgment, payer decisions, and cash movement attributable to the right roles.

Start or grow your ABA practice with Finni. Confirm current billing capabilities, payer support, implementation responsibilities, security terms, and validation evidence during diligence.