Resources
Practical guides for cleaner healthcare revenue operations.
Operating knowledge — not marketing fluff. Answer-first guides, checklists, and a plain-English glossary for practices, clinics, and pharmacies that want cleaner claims and faster collections.
Guides & checklists
Read these first.
How to Reduce Claim Denials: A Prevention-First Guide
How to reduce claim denials: common CARC denial codes and fixes, root causes, a five-step prevention workflow, and the denial metrics to track monthly.
Read the guideHow to Read an AR Aging Report (and Find Where Revenue Leaks)
How to read a medical AR aging report: what each aging bucket means, how to calculate days in AR and net collection rate, and how to prioritize AR follow-up.
Read the guideInsurance Eligibility Verification Checklist for Front-Desk Teams
Front-desk insurance eligibility verification checklist: when to verify, what to confirm, coordination of benefits rules, and Medicare and Medicaid tips.
Read the guideProvider Credentialing for Small Practices: CAQH, Payer Enrollment, and Revalidation
How provider credentialing and payer enrollment work: documents needed, CAQH ProView, Medicare PECOS, typical timelines, and revalidation schedules.
Read the guideHIPAA-Compliant Medical Billing: The Controls That Actually Matter
What HIPAA-compliant medical billing requires: BAAs, minimum necessary access, MFA, encryption, breach notification deadlines, and vendor questions.
Read the guideMedical Coding Accuracy: Reduce Coding Denials Without Burning Out Coders
Improve medical coding accuracy: why coding denials happen, the ICD-10-CM, CPT, and HCPCS update calendar, modifier risks, and a coding audit program.
Read the guideHow to Choose a Medical Billing Company: 12 Questions to Ask Before You Sign
How to choose a medical billing company: 12 questions to ask, red flags to avoid, pricing models explained, and what should be in a medical billing contract.
Read the guideIn-House vs. Outsourced Medical Billing: How to Decide
In-house vs. outsourced medical billing: true costs, control, staffing risk, the hybrid model, signs it is time to outsource, and how to switch safely.
Read the guidePharmacy Claim Rejections and DIR Fees: A Guide for Independent Pharmacies
Common NCPDP pharmacy reject codes and how to resolve them, what changed with Part D DIR fees in 2024, PBM remittance reconciliation, and how to stay audit-ready.
Read the guideGlossary
Healthcare RCM terms, in plain English.
The billing, coding, and compliance terms that come up most in revenue cycle work.
- RCM (Revenue Cycle Management)
- The end-to-end process of capturing, billing, and collecting payment for healthcare services — from scheduling and eligibility through claims, denials, payment posting, and patient collections.
- Days in AR
- The average number of days it takes to collect payment after a service is billed, calculated as total accounts receivable divided by average daily charges.
- Clean Claim Rate
- The percentage of claims accepted on first submission without rejections, edits, or requests for more information.
- First-Pass Resolution Rate
- The percentage of claims paid in full on the first submission, with no rework.
- Denial Rate
- The percentage of submitted claims that payers deny, in full or in part, on first adjudication.
- Net Collection Rate
- Payments collected divided by charges minus contractual adjustments — how much collectible revenue is actually collected.
- CARC (Claim Adjustment Reason Code)
- The standard code on a remittance explaining why a claim or line was paid differently than billed — for example, CO-197 for missing authorization.
- RARC (Remittance Advice Remark Code)
- A supplemental code on a remittance that adds detail to a CARC.
- ERA (835)
- Electronic Remittance Advice — the HIPAA X12 835 transaction payers send to explain claim payments, adjustments, and denials.
- EOB (Explanation of Benefits)
- A payer statement explaining how a claim was processed; the paper or patient-facing counterpart of the ERA.
- 837 Claim
- The HIPAA X12 837 transaction used to submit professional (837P) and institutional (837I) claims electronically.
- 270/271 Eligibility Transaction
- The HIPAA X12 eligibility inquiry (270) and response (271) used to check insurance coverage and benefits electronically.
- CPT
- Current Procedural Terminology — the American Medical Association’s code set for medical procedures and services, updated annually on January 1.
- ICD-10-CM
- The U.S. diagnosis code set used on claims to establish medical necessity, updated annually on October 1.
- HCPCS Level II
- The CMS code set for supplies, drugs, durable medical equipment, and services not described by CPT, updated quarterly.
- NCCI Edits
- National Correct Coding Initiative edits — CMS rules identifying procedure pairs that should not be billed together and unit counts that exceed medically likely limits.
- Modifier
- A two-character code appended to a CPT or HCPCS code to add information, such as a separately identifiable service (25), a distinct procedure (59), or laterality (LT/RT).
- E/M (Evaluation and Management)
- CPT codes for visits and consultations, with the level selected by medical decision making or total time on the date of the encounter.
- Prior Authorization
- Payer approval required before certain services, procedures, or medications are provided in order for them to be covered.
- COB (Coordination of Benefits)
- The rules that determine which payer is primary when a patient has more than one coverage.
- Timely Filing Limit
- A payer’s deadline for submitting a claim after the date of service; late claims are denied (CARC 29).
- Credentialing
- Verification of a provider’s licensure, education, training, and professional history, typically performed by payers before enrollment.
- CAQH ProView
- A provider data repository many commercial payers use for credentialing; profiles must be re-attested every 120 days.
- NPI (National Provider Identifier)
- The unique 10-digit HIPAA identifier for healthcare providers — Type 1 for individuals, Type 2 for organizations.
- PECOS
- Provider Enrollment, Chain, and Ownership System — the CMS online system for Medicare enrollment and revalidation.
- BAA (Business Associate Agreement)
- A HIPAA-required contract between a covered entity and a vendor that creates, receives, maintains, or transmits PHI on its behalf.
- PHI (Protected Health Information)
- Individually identifiable health information — including billing and payment information — protected under HIPAA.
- PBM (Pharmacy Benefit Manager)
- The company that administers prescription drug benefits and adjudicates pharmacy claims on behalf of health plans.
- DIR Fees
- Direct and Indirect Remuneration — price concessions pharmacies pay to PBMs and Part D plans; since 2024, Medicare Part D concessions must be applied at the point of sale.
- NCPDP
- The standards organization whose Telecommunication Standard is used to submit and adjudicate pharmacy claims in real time.
- Good Faith Estimate
- An estimate of expected charges that providers must give uninsured and self-pay patients for scheduled services under the No Surprises Act.
Resources FAQ
Common questions.
Quick, direct answers to the questions providers ask most about LRx Healthcare.
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