Medical Billing Terms Q-R: RARC Codes, Recoupment and Recovery Audits

Also called QHP; Marketplace-certified plan

Definition

A qualified health plan (QHP) is an insurance plan certified by the Health Insurance Marketplace. It covers the essential health benefits, keeps cost-sharing within set limits, and meets other Affordable Care Act requirements.

Why it matters

Marketplace plans must cover mental health and substance use care as an essential health benefit, with parity on costs, treatment limits and care management. Exact benefits vary by state and plan.

Illustrative example

A new patient has a Marketplace plan. The practice checks that behavioral health visits are covered and what the plan's cost-sharing is.

Related termsMarketplace PlanEssential Health Benefits (EHB)Qualifying Life Event (QLE)

Reference sourceHealthCare.gov: Qualified health planchecked 10/9/26

CategoriesEligibility & Benefits

Also called QIC; second-level Medicare appeal

Definition

The second level of appeal in Original Medicare, decided by a QIC.

Why it matters

Follows redetermination.

Illustrative example

A provider escalates to a QIC after redetermination is unfavorable.

Related termsRedeterminationAdministrative Law Judge (ALJ) Hearing

Reference sourceCMS (Centers for Medicare & Medicaid Services)CMS Medicare Learning Network (MLN)checked 10/9/26

CategoriesDenials & AppealsMedicare & Medicaid Terms

Also called QMB; QMB billing rules

Definition

A Medicaid program category in which the state pays Medicare cost sharing for eligible people. Providers generally may not bill QMB enrollees for Medicare cost sharing.

Why it matters

Billing a QMB patient for Medicare cost sharing can violate federal rules.

Illustrative example

A QMB patient's copay is sent to the state Medicaid program, not to the patient.

Related termsDual EligibleBalance BillingCrossover Claim

Reference sourceCMS (Centers for Medicare & Medicaid Services)CMS Medicare Learning Network (MLN)checked 10/9/26

CategoriesMedicare & Medicaid TermsPatient Financial Responsibility Terms

Also called QLE; special enrollment trigger

Definition

A qualifying life event (QLE) is a change in circumstances, such as losing other coverage, a household change like marriage or a new child, a move, or a change in income, that can open a Special Enrollment Period for Marketplace coverage. The examples on HealthCare.gov are not a complete list.

Why it matters

A patient's coverage can change in the middle of the year, so the practice rechecks eligibility before the next visit.

Illustrative example

A patient mentions a recent move and a new plan. The front desk reruns eligibility before the next session.

Related termsQualified Health Plan (QHP)Eligibility VerificationMarketplace Plan

Reference sourceHealthCare.gov: Qualifying life event (QLE)checked 10/9/26

CategoriesEligibility & Benefits

Also called QIO; BFCC-QIO

Definition

A Quality Improvement Organization (QIO) is a group under contract with CMS that works to improve the quality of care for people with Medicare. Beneficiary and Family Centered Care (BFCC) QIOs take quality-of-care complaints and early-discharge appeals.

Why it matters

It is mainly a Medicare term. A practice usually meets a QIO only when a Medicare patient files a quality-of-care complaint. CMS changes the contractors over time, so check the CMS page for current names.

Illustrative example

A Medicare patient files a quality-of-care complaint, and the BFCC-QIO asks the practice for records.

Related termsMedicare Administrative Contractor (MAC)Medical Necessity

Reference sourceCMS: Beneficiary and Family Centered Care (BFCC)-QIOschecked 10/9/26

CategoriesMedicare & Medicaid TermsAudits & Compliance

Also called QPP

Definition

The CMS program for Medicare clinician payment adjustments based on quality, including MIPS and advanced APMs.

Why it matters

Some practices are exempt or below thresholds; eligibility must be checked.

Illustrative example

A practice checks its MIPS eligibility each year.

Related termsMIPS (Merit-Based Incentive Payment System)MACRA

Reference sourceCMS (Centers for Medicare & Medicaid Services)CMS Quality Payment Programchecked 10/9/26

CategoriesValue-Based Care TerminologyQuality & Risk Adjustment Terms

Also called QTL; visit limit rule; day limit

Definition

A quantitative treatment limitation (QTL) is a numerical limit on a benefit, such as a visit limit or a day limit.

Why it matters

Under the Mental Health Parity and Addiction Equity Act, a limit on a mental health or substance use benefit cannot be more restrictive than the limit on comparable medical or surgical benefits. Non-numerical rules such as prior authorization are separate limits, called NQTLs.

Illustrative example

A plan caps therapy at 20 visits a year, while comparable medical visits have no cap. The practice asks the plan whether the limit meets parity rules.

Related termsNon-Quantitative Treatment Limitation (NQTL)Mental Health Parity (MHPAEA)

Reference sourceCMS: Mental Health Parity and Addiction Equity Act (MHPAEA)checked 10/9/26

CategoriesEligibility & BenefitsAudits & Compliance

Also called RADV audit

Definition

A CMS audit process that checks whether diagnoses submitted for Medicare Advantage risk adjustment are supported by medical records.

Why it matters

Plans may request records from providers to support diagnoses.

Illustrative example

A plan asks a practice for records supporting a diagnosis.

Related termsRisk AdjustmentAuditGuide: Payer audits

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesQuality & Risk Adjustment TermsAudits & Compliance

Also called RARC; remark code

Definition

A code that adds detail to a CARC on an ERA, maintained by CMS.

Why it matters

Provides specifics that guide the fix.

Illustrative example

A RARC explains which missing item caused a denial.

Related termsCARC (Claim Adjustment Reason Code)Remittance Advice (ERA)Guide: CARC and RARC codes

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesDenials & AppealsEDI & Clearinghouse Terms

Also called revenue cycle management software; RCM software; billing platform

Definition

Software that supports billing steps such as eligibility, claim scrubbing, submission, posting, and denial follow-up.

Why it matters

Can reduce manual work but needs monitoring.

Illustrative example

A biller works a denial queue inside an RCM platform.

Related termsPractice Management System (PMS)Revenue Integrity Solution

Reference sourceHFMAchecked 10/9/26

CategoriesEHR & Healthcare Technology TermsRevenue Cycle Metrics

Also called real-time eligibility; real-time claim status

Definition

An electronic request answered immediately, rather than in a batch.

Why it matters

Supports front-desk workflows.

Illustrative example

A front desk checks eligibility in seconds.

Related terms270/271 Eligibility TransactionBatch TransactionGuide: Claim status inquiry

Reference sourceCAQHX12checked 10/9/26

CategoriesEDI & Clearinghouse Terms

Also called Medicare reasonable and necessary standard; Section 1862(a)(1)(A); medically reasonable and necessary

Definition

Reasonable and necessary is Medicare's basic coverage standard. Medicare generally pays only for services that are reasonable and necessary for the diagnosis or treatment of illness or injury.

Why it matters

It is the Medicare form of medical necessity. Notes should show why the service was needed, not just that it happened.

Illustrative example

A note describes the patient's symptoms, the intervention, and the goal, which supports the reasonable and necessary standard.

Related termsMedical NecessityMedical Necessity CriteriaDocumentationMedical Record Audit

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesMedicare & Medicaid TermsAudits & Compliance

Also called CMS-855R; reassignment; reassigning Medicare payments

Definition

A Medicare enrollment action that lets an eligible provider assign the right to receive Medicare payment to a group or organization.

Why it matters

Without it, Medicare payment cannot go to the group.

Illustrative example

A group files enrollment paperwork so a psychologist's Medicare payments go to the group's account.

Related termsMedicare Enrollment (PECOS)CMS-855Group Enrollment

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesCredentialing & EnrollmentMedicare & Medicaid Terms

Also called payer reconsideration; first-level appeal; claim review request

Definition

A request that the payer re-review a claim decision, often the first step before a formal appeal or, in Medicare Part B, a step after redetermination.

Why it matters

Some payers treat reconsideration as a lighter step, and it may not preserve formal appeal rights.

Illustrative example

A practice sends a reconsideration request with a corrected diagnosis.

Related termsAppealRedeterminationQualified Independent Contractor (QIC) Reconsideration

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesDenials & Appeals

Also called payer recoupment; clawback

Definition

A payer's recovery of money it says it overpaid, often by deducting it from future payments.

Why it matters

Recoupments shrink remittances and can be disputed.

Illustrative example

A payer recoups a prior payment through offsets against new claims.

Related termsTakebackOffsetOverpaymentRefund RequestGuide: Payer audits

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesPayment & ReimbursementDenials & Appeals

Also called RAC; recovery audit

Definition

A CMS contractor that reviews Medicare and Medicaid payments to find improper payments.

Why it matters

RAC findings can lead to overpayment demands.

Illustrative example

A RAC reviews claims and requests records.

Related termsAuditOverpaymentMedicare Administrative Contractor (MAC)Guide: Payer audits

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesAudits & ComplianceMedicare & Medicaid Terms

Also called re-credentialing; recredentialing cycle

Definition

The periodic review a payer repeats to confirm a network clinician still meets its standards. Many payers repeat it on a multi-year cycle set by the payer.

Why it matters

Missing a recredentialing request can lead to termination from the network and claim denials.

Illustrative example

A payer emails a recredentialing notice; the practice updates its profile and attests before the deadline.

Related termsCredentialingAttestationCAQH ProViewNetwork Termination

Reference sourceNCQAchecked 10/9/26

CategoriesCredentialing & Enrollment