Glossary

The process of formally receiving, logging, and preparing a specimen or test order for processing at a lab, capturing patient demographics, test selections, and specimen details, and assigning a unique identifier for tracking through the workflow.

A group of providers who share financial and clinical responsibility for a defined patient population, with the goal of improving quality while controlling cost. Central to most value-based care contracts.

The process a payer uses to review a submitted claim and decide how much, if anything, to pay, based on coverage rules, medical necessity, and coding accuracy.

A defined way for two software systems to exchange data automatically. In healthcare, APIs are the mechanism behind most modern data exchange, including FHIR-based interoperability.

A formal request from a provider asking a payer to reverse or reconsider a denied claim, usually requiring additional documentation to support the original claim.

An xCures product that assembles a longitudinal patient record automatically from all available sources, creating one structured view of a patient’s history instead of a scattered set of documents.

A measurable biological indicator, such as a protein, gene, or molecule, used to detect disease, predict risk, or guide treatment decisions. Central to most molecular diagnostic tests.

A standardized document format used to exchange clinical summaries, such as discharge summaries or continuity of care documents, between healthcare systems.

A discrepancy between recommended care, based on clinical guidelines or a quality measure, and the care a patient has actually received or documented. A key focus area in value-based care.

A national interoperability framework that lets health information networks exchange records under one common legal agreement.

The process of reading through a patient’s medical record to find specific information needed for a decision, such as a diagnosis, a treatment date, or documentation supporting medical necessity. Traditionally manual, and often the slowest step in both clinical and billing workflows.

When a payer refuses to reimburse a provider for a submitted claim, either permanently (a hard denial) or temporarily, pending correction or appeal (a soft denial). Denials are one of the largest sources of preventable revenue loss in healthcare billing.

The percentage of claims accepted by a payer on first submission, without needing correction or resubmission. A widely used revenue cycle health metric, higher is better.

The layer between data access and clinical action: decision-ready clinical understanding, structured, verified, and traceable to its source.

xCures’s core platform. xCures® is the Clinical Clarity Engine for healthcare, assembling and structuring patient medical records into decision-ready data.

The process of pulling specific, structured data points out of unstructured clinical documents (notes, reports, records) so they can be used in a downstream workflow like billing, quality reporting, or clinical decision-making.

A set of practices and tools aimed at making clinical documentation more accurate, specific, and complete, usually to support correct coding, quality measurement, and reimbursement.

A test used alongside a specific drug or treatment to determine whether a patient is likely to benefit from it, common in oncology and precision medicine.

A standardized code set describing medical procedures and services, used across billing, reporting, and reimbursement.

The average number of days it takes a provider to collect payment after a claim is submitted. A standard revenue cycle benchmark, lower is generally better.

An xCures capability that shows exactly what information is needed for a specific decision (such as medical necessity or prior authorization) and returns structured outputs matched against what a patient’s record already contains, with every item linked back to its source.

The broader process of identifying, tracking, appealing, and preventing claim denials, distinct from a single appeal. Includes root-cause analysis to reduce recurring denial patterns.

A subset of CPT codes describing the level of a patient visit or encounter, based on complexity and time. Frequently a source of coding disputes and audits.

An EMR (Electronic Medical Record) is a digital version of a patient’s chart within one practice. An EHR (Electronic Health Record) is designed to be shared across providers and organizations, giving a broader view of a patient’s history. The terms are often used interchangeably in practice, though the distinction matters for interoperability.

A statement from a payer explaining how a claim was processed, what was covered, what the patient owes, and why any portion was denied.

An xCures capability describing data where every extracted element is traceable back to its exact source document and page, making outputs independently verifiable.

The modern standard for exchanging healthcare data electronically. xCures outputs standardize to FHIR R4.

The percentage of claims paid correctly the first time they’re submitted, without rework. Related to clean claim rate, sometimes used interchangeably depending on the organization.

A risk-adjustment coding model used mainly in Medicare Advantage and value-based care, where diagnosis codes are grouped into categories that predict a patient’s expected cost of care.

A code set used mainly for billing supplies, equipment, and services not covered by CPT codes, common in Medicare and Medicaid billing.

A widely used set of standardized quality measures that health plans report to evaluate and compare performance, covering areas like preventive screening, chronic disease management, and access to care. HEDIS® is a registered trademark of the NCQA.

An organization or network that enables healthcare providers and organizations to electronically share patient information across different systems.

A certification framework for organizations that handle sensitive health data. The xCures Engine is HITRUST certified.

A set of international standards for exchanging clinical and administrative healthcare data between systems, the predecessor to and still widely used alongside FHIR.

A standardized code set used to classify diagnoses. Every billed claim needs at least one ICD-10 code to justify medical necessity.

The ability of different healthcare IT systems, EHRs, labs, payers, to exchange and make use of patient data across organizational boundaries.

A diagnostic test designed, manufactured, and used within a single laboratory, rather than sold commercially. Common in molecular diagnostics and subject to a different regulatory pathway than FDA-approved tests.

A patient’s history assembled across every provider, system, and time period — one continuous story rather than scattered episodes.

A payer’s determination of whether a service or test was clinically appropriate and required for a patient’s diagnosis or treatment, one of the most common bases for both approval and denial of a claim.

The process of a person (traditionally a nurse or coder) reading through a patient chart by hand and pulling out the specific data points a claim, registry, or quality measure requires.

A two-character code added to a CPT or HCPCS code to clarify how a service was performed, without changing the definition of the service itself. Commonly a source of billing errors when applied incorrectly.

A category of laboratory testing that analyzes DNA, RNA, or other molecular biomarkers, rather than traditional chemistry or culture methods, to detect disease, guide treatment, or assess risk. Often carries higher documentation and prior authorization requirements than routine lab testing.

A genomic testing method that reads many DNA or RNA fragments in parallel, commonly used in molecular diagnostics for broader genetic profiling than single-gene tests.

A document summarizing a pathologist’s findings from examining tissue, blood, or other samples, frequently required as supporting documentation for medical necessity and molecular diagnostic claims.

A requirement from a payer that a provider obtain approval before performing certain services or tests, based on the payer’s own medical necessity criteria. A major source of delay and denial risk in diagnostics and specialty testing.

An organization approved under TEFCA to connect multiple health information networks, enabling nationwide query and exchange of patient records.

A standardized metric used to evaluate the quality of care delivered, such as a HEDIS measure or a CMS Star Rating component. Often tied directly to reimbursement in value-based contracts.

CMS’s audit program verifying that submitted diagnoses are supported by medical record documentation. CMS now audits all eligible Medicare Advantage contracts annually.

A numeric score representing a patient’s predicted cost of care, calculated from diagnosis codes, often HCCs, and demographic factors. Used to adjust payments in Medicare Advantage and other risk-based contracts.

The amount a payer actually pays for a given service or claim, which can differ significantly from the amount billed.

The broader methodology payers use to account for differences in patient health status when setting payments or comparing outcomes. RAF scores are one output of this process.

Traceable to the exact document, page, and passage a data element came from. Source-linking is what makes an extracted answer verifiable rather than merely plausible.

CMS’s five-star quality rating system for Medicare Advantage and Part D plans, based on a mix of clinical quality, member experience, and operational measures. Directly affects plan reimbursement and enrollment.

Information organized into a predictable, predefined format (fields, codes, tables) that a computer system can process directly, as opposed to free text.

An itemized form, generated by a provider, listing the services rendered, diagnosis codes, and procedure codes for a patient visit, used as the basis for generating a claim.

A federal framework establishing common terms and technical standards for health information exchange across networks nationwide.

The document that accompanies a specimen or test order, capturing patient demographics, insurance information, diagnosis, and the specific tests requested. A frequent source of downstream billing and coverage problems when incomplete.

Information that doesn’t reside in predefined fields, such as free-text clinical notes, scanned documents, or narrative reports. Estimated to make up the majority of healthcare data, and the hardest to use without extraction and structuring.