Finance

A payment made between health plans in the same market under the ACA risk adjustment program, transferring funds from plans with lower-than-average risk enrollees to plans with higher-than-average risk enrollees based on the relative risk scores of each plan enrolled population. Risk transfer payments are calculated by CMS and HHS using HHS-HCC risk adjustment models and are zero-sum within each market and state, designed to neutralize incentives for risk selection and ensure premiums reflect benefits rather than enrollee health status.

A systematic process of investigating the underlying causes of claim denials to identify and correct the source problems rather than merely resolving individual denied claims. Effective denial root cause analysis categorizes denials by type, traces each denial category to its point of origin in the revenue cycle workflow, identifies the specific process failures or system deficiencies causing the denial pattern, and implements targeted process improvements to prevent recurrence. Root cause analysis transforms denial management from a reactive claim-by-claim rework process into a proactive quality improvement program that reduces denial rates over time. Common root causes include registration errors producing eligibility denials, inadequate prior authorization processes causing authorization denials, coding errors producing medical necessity denials, and untimely claim submission causing timely filing denials. Healthcare data teams build rca_denial analytics that categorize denial volumes and dollars by root cause, track resolution rates by category, and measure denial rate reduction from specific process improvements to demonstrate revenue cycle return on investment.

The unique account identifier associated with a specific medication administration route, such as oral, intravenous, or subcutaneous, within pharmacy or clinical systems. Used to link route-specific drug administration records to patient accounts in pharmacy claims, medication management, or clinical data platforms.

The total expense associated with a specific medication administration route, such as intravenous infusion or subcutaneous injection, including drug acquisition, supplies, and administration labor. Used in pharmacy cost analysis and claims reporting to evaluate expenditures by drug delivery pathway.

The unique account identifier linked to a biological specimen collected for diagnostic or laboratory testing, such as blood, urine, or tissue samples. Used to associate specimen collection and processing activities with the correct patient account across laboratory information systems and clinical data records.

The total expense associated with collecting, handling, processing, and storing a biological specimen for diagnostic or laboratory purposes. Captures costs including specimen collection supplies, transportation, and laboratory processing fees recorded in laboratory billing and clinical data systems.

The unique account identifier linked to a patient satisfaction survey or experience measurement record. Used to associate patient-reported experience data with specific encounters, care episodes, or member accounts across patient experience platforms, health plan systems, and quality reporting programs.

The total expense associated with administering, collecting, and analyzing patient satisfaction surveys or experience measurement programs. Captures costs related to survey distribution, data collection, vendor fees, and reporting activities tied to CAHPS or other patient experience initiatives.

The unique account identifier associated with a diagnostic imaging scan, such as an MRI, CT, or PET scan, within radiology or clinical data systems. Used to link imaging procedures and their associated findings to the correct patient account across radiology information systems and claims records.

The total expense associated with performing a diagnostic imaging scan, including equipment usage, radiologist interpretation, technical fees, and facility charges. Used in radiology cost analysis and claims reporting to track imaging expenditures by modality, setting, or patient population across health plan and provider systems.

A healthcare claim submitted to a secondary insurance payer after the primary payer has adjudicated the claim and made its payment determination, seeking reimbursement for remaining patient balance from the second insurance coverage. Secondary billing applies when a patient has dual insurance coverage under coordination of benefits rules, with the primary payer paying first according to COB priority rules and the secondary payer potentially covering some or all of the remaining balance including deductibles, copays, and coinsurance from the primary adjudication. Common secondary billing scenarios include Medicare as secondary to employer group insurance, Medicaid as secondary to commercial insurance for dual eligible members, and dependent children covered under both parents employer plans. Healthcare data teams build secondary billing workflows that automatically identify claims with secondary payer information, generate secondary claims from primary remittance advice data, track secondary claim payment rates and timelines, and calculate the net revenue contribution from secondary billing programs.

A boolean indicator identifying a patient who has no health insurance coverage and is therefore personally responsible for the full cost of healthcare services without third-party payer reimbursement. Self-pay patients represent a distinct revenue cycle segment requiring specialized registration, financial counseling, and collection workflows different from insured patients. Self-pay patients are typically offered prompt-pay discounts, sliding scale charity care based on income, and payment plan arrangements to make care financially accessible and maximize collection rates. Self-pay collection rates are significantly lower than insured patient collection rates, requiring careful bad debt reserve modeling. Healthcare data teams analyze self_pay_ind trends by service type and geography to assess community health access, calculate self-pay bad debt reserves, measure the effectiveness of financial counseling programs in converting self-pay patients to Medicaid or marketplace coverage, and monitor self-pay volume changes resulting from coverage expansion or contraction in the market.

Unique identifier assigned to an allergy or substance sensitivity record in clinical systems. Used to track patient-specific reactivity data across encounters, link sensitivity records to billing events, and maintain continuity of allergy documentation throughout the care continuum.

The recorded expense associated with diagnosing, documenting, or managing a patient's allergy or substance sensitivity. Captures costs tied to allergy testing, clinical evaluation, and documentation workflows in healthcare billing and cost accounting systems.

Unique identifier assigned to a serology test order or result record in laboratory and clinical systems. Used to track antibody study results, link serum-based diagnostic findings to patient encounters, and support longitudinal lab result management across healthcare data systems.

The recorded expense associated with performing or interpreting serum antibody studies, including lab processing, reagent usage, and reporting. Captured in laboratory billing and cost accounting systems to support financial analysis of diagnostic testing activity.

Unique identifier assigned to a specific clinical or administrative service delivered during a patient encounter. Used to link billable activities to accounts receivable records, support claims adjudication, and enable service-level tracking across revenue cycle management systems.

The recorded expense associated with delivering a specific clinical or administrative service to a patient. Captured in cost accounting and revenue cycle systems to support pricing analysis, reimbursement reconciliation, and operational reporting at the service line level.

Unique identifier assigned to a discrete therapy or treatment session, such as physical therapy, behavioral health, or infusion visit. Used to link individual session records to patient accounts, track cumulative utilization, and support claims billing across care management systems.

The remaining unpaid amount owed by a payer or patient for a specific therapy or treatment session after payments and adjustments have been applied. Tracked in revenue cycle systems to manage collections, monitor accounts receivable aging, and reconcile session-level financial activity.