Review-nursing glossary

The vocabulary of remote review work, in plain language.

Every review nurse, coder, and biller works in the same shared language - utilization management, prior authorization, denials, appeals, and the codes that explain them. These are the terms you will hear on day one, defined as neutral industry concepts. Commercial medical-necessity criteria sets are named only in the abstract; RemoteNurse teaches review reasoning with its own original synthetic framing, never proprietary criteria.

Review workflow

Utilization managementUM: The payer-side process of reviewing whether a requested or delivered service is appropriate and covered. It spans prospective, concurrent, and retrospective review, and it is the umbrella most remote review-nurse roles sit under.
Prior authorizationPA: A payer's advance approval of a service before it is delivered. A reviewer checks the request against plan rules and medical-necessity guidance, then approves, pends for more information, or routes it for a coverage determination.
Prospective review: Review done before care is delivered, such as a prior authorization. The goal is to confirm the requested service is appropriate and supported before it happens.
Concurrent review: Review done while a patient is still receiving care, typically during an inpatient stay. The reviewer checks that the ongoing level of care remains supported by the current documentation.
Retrospective review: Review done after care has already been delivered, usually when no advance authorization was obtained. The reviewer evaluates the completed record against the applicable rules.
Peer-to-peerP2P: A conversation between the requesting clinician and the payer's physician reviewer when a case cannot be approved on documentation alone. Nurse reviewers prepare and route these; the coverage decision itself belongs to the physician reviewer.
Turnaround timeTAT: The time a reviewer has to complete a decision, set by regulation or plan policy. Missing a TAT deadline can itself change the outcome, so watching the clock is part of the workflow.
Level of care: The intensity of setting a patient's condition supports - for example inpatient, observation, or a lower-acuity setting. Matching documentation to the right level of care is a core concurrent-review task.
Medical necessity: The standard that a service is reasonable and appropriate for the patient's condition under the plan's rules. Reviewers assess whether the record supports it; they do not diagnose or direct treatment.
Discharge planning: Coordinating a safe next setting as an inpatient stay winds down. Review nurses flag when the documented plan and the record disagree so the gap can be resolved before discharge.
Medical-necessity criteria sets: Commercial guideline products (for example MCG or InterQual) that some payers license to structure medical-necessity review. They are proprietary to their publishers. RemoteNurse does not reproduce or paraphrase any proprietary criteria; it teaches review reasoning with its own original synthetic framing.

Regulatory

Two-Midnight rule: A Medicare guideline that generally expects an inpatient admission when a physician reasonably expects the patient to need care spanning two midnights. It commonly drives the observation-versus-inpatient question in concurrent review.
Observation versus inpatient: The status distinction between a shorter observation stay and a full inpatient admission. The two carry different coverage and billing consequences, so the supporting documentation has to match the status assigned.
Prior-authorization clock: The regulated deadline for a prior-authorization decision. Expedited requests generally allow about 72 hours and standard requests about 7 days, though exact windows vary by program and plan - always confirm the rule that applies.
Expedited review: A faster review track used when waiting the standard timeframe could seriously jeopardize the patient. It shortens the turnaround-time window, so the clock is tighter.
Grievance: A member complaint about the quality or handling of care or service, distinct from an appeal of a specific coverage decision. Plans log and respond to grievances under their own timelines.
External review: An independent review of a denial by an outside organization after internal appeals are exhausted. It moves the final call outside the plan that issued the denial.

Claims & billing

Claim: A provider's request to a payer for payment for services delivered. The claim carries the codes, dates, and charges the payer adjudicates against the member's benefits.
Denial: A payer's decision not to pay a claim, in full or in part. A denial arrives with reason codes that explain why and point toward what a resubmission or appeal would need to address.
Appeal: A formal request to reconsider a denial. A first-level (Level 1) appeal goes back to the payer; a second-level (Level 2) appeal escalates within the plan or to an independent reviewer, depending on the program.
Claim adjustment reason codeCARC: A standardized code on a remittance that explains why a claim's payment was adjusted or reduced. Reading CARCs correctly is how a biller learns what a denial actually turned on.
Remittance advice remark codeRARC: A supplemental code that adds detail to a CARC on a remittance, clarifying the adjustment further. CARCs and RARCs are read together to reconstruct a payer's reasoning.
Explanation of benefitsEOB: The member-facing statement showing how a claim was processed - what was billed, allowed, paid, and left to the member. It is a notice, not a bill.
835 remittance advice835: The electronic remittance transaction a payer sends a provider to report claim payment and adjustment detail. It is the machine-readable counterpart to the paper remittance a biller reconciles against.
Clean claim: A claim submitted with complete, correct information that can be adjudicated without needing more from the provider. Clean claims move faster and deny less often.

Coverage & eligibility

271 eligibility response271: The electronic reply to a benefits inquiry, confirming a member's coverage and cost-sharing details. Checking the 271 before work is authorized prevents avoidable downstream denials.
Eligibility: Whether a member is actively covered under a plan on the date of service. Eligibility is the first thing a reviewer or biller confirms before anything else in the record matters.
Coordination of benefitsCOB: The rules that decide which plan pays first when a member has more than one. Getting the order right is a common source of, and fix for, avoidable denials.
Coverage determination: The plan's formal decision about whether a specific service is covered for a member. Nurse reviewers assemble and document the record that supports the decision; the determination itself follows the plan's process.
Formulary: The list of drugs a plan covers, often with tiers and prior-authorization requirements. A medication prior authorization is checked against the formulary and its rules.

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