Glossary

Everything from scheduling and eligibility, through coding, claim submission, payer adjudication, payment posting, denial work, and patient collections. This site is the operating layer for RCM.

What the practice actually expects to keep after payer contracts. Different from cash collected — net revenue is recognized when services are billed, cash arrives later.

Cash that hit the bank and was reconciled in the PM system. The lag between billing and cash posting is one of the most-watched RCM metrics.

Built from open AR, historical payer behavior, denial probabilities, and seasonality. Used by finance for payroll, vendor payments, and distributions.

If you charge $500 and the contracted rate is $310, the $190 difference is a contractual — not a denial. Tracking unexpected contractuals catches under-contracted services.

Can be administrative (small balance), contractual, charity care, or bad debt. Write-off rate trending up usually points to denial or eligibility upstream issues.

Contains CPT (what was done), ICD-10 (why), modifiers, place of service, and the rendering provider. Submitted electronically via an 837 file through a clearinghouse.

Industry benchmark is 95%+. Anything lower means rework cost, cash delay, and a higher chance the claim ages past timely-filing limits.

Comes back with a CARC (claim adjustment reason code) and RARC (remark code) explaining why. Common buckets: eligibility, authorization, coding, medical necessity, timely filing.

Watch both: count tells you operational pain, dollars tell you cash exposure. A 6% count denial rate at one payer might be 18% of dollars if the high-value services are the ones denying.

Typically requires a letter, clinical documentation, and submission within a payer-specific window (often 90–180 days). Copilot can draft appeal packets pre-populated with the right evidence.

Denials, rejections, missing info, unposted payments, credit balances, etc. The Control Tower routes these into owner-specific workqueues with SLA timers.

CARC = Claim Adjustment Reason Code (e.g. CO-50 'not medically necessary'). RARC = Remittance Advice Remark Code, adds context. Used to auto-categorize denials.

Catches format errors before the payer sees them — those are 'rejections,' not denials. Examples: Change Healthcare, Availity, Waystar.

The 835 file tells you what was paid, what was adjusted, and why. Auto-posting parses it into the PM system; mismatches become posting exceptions.

Split into payer AR (insurance owes) and patient AR (patient owes after insurance). Total AR ÷ average daily charges = Days in AR.

Healthy specialty practice: 30–45 days. Above 50 means cash is stuck somewhere — usually denials, posting backlog, or patient balances.

Standard buckets: 0–30, 31–60, 61–90, 91–120, 120+ days. Anything past 90 days collects at a much lower rate — that's why AR > 90d is a headline KPI.

Miss it and the claim is automatically denied with no appeal rights. Ranges from 90 days (some commercial) to 365 (Medicare). Aged unbilled claims are an emergency.

Calculated from aging bucket, payer, denial reason, and remaining timely-filing window. The Control Tower surfaces this so teams work the highest-recovery items first.

Run before every visit. A failed eligibility check upstream is the #1 cause of downstream denials. Real-time eligibility uses the 270/271 transaction.

Required for many specialty procedures, imaging, and infusions. Missing or expired PA is a hard denial — and usually non-appealable.

Often the slowest-collecting AR. Sending a clear statement within 7 days of EOB posting roughly doubles patient-pay collection rate.

Used to link clinical, demographic, and billing records. One patient can have multiple insurance subscribers but only one MRN per practice.

Self-pay AR behaves very differently from payer AR — higher write-off rate, longer collection cycle, more sensitivity to statement quality.

Close cousin to CCR, but stricter: counts only claims paid at expected contract rate on first submission. The gold-standard operational KPI.

Cash collected ÷ (charges − contractuals). Anything under 95% means you're leaving money on the table to denials, write-offs, or patient bad debt.

Best-in-class specialty practices run 2–4%. AI-assisted workflows in this platform target sub-3%.

E.g. 'all denials touched within 5 business days.' SLA breach risk on KPIs flags items aging past the promise.

Used everywhere: revenue variance to budget, payment variance to contract, posting lag variance to baseline. Copilot's 'Explain variance' action breaks the gap into named drivers.

Commercial vs. Medicare vs. Medicaid vs. self-pay. Mix shifts directly move net revenue even at constant volume.

Default deltas on KPI cards. WoW catches operational drift fast; YoY normalizes seasonality.

Knows what you're looking at, explains numbers, drafts appeal letters, suggests next actions, and can be asked anything in plain English. Floating button bottom-right.

E.g. auto-assigning unowned exceptions to the best-fit specialist, or auto-drafting appeals for a denial cluster. Always reviewable before send.

KPI cards, chart segments, and table rows open a side drawer with the breakdown and an 'Explain this number' button that seeds Copilot with the right context.

Instead of FIFO, the workqueue surfaces the items most likely to convert cash this week. Shows a confidence score per recommendation.