| Entity |
Description |
| Authorization |
Indicating that a service is allowed to be performed for a member. This is done to
minimize the use of services that might not be required. There are various levels and
types of authorizations, depending on the treatment requested. A member must generally
receive an authorization from their PCP to see a specialist. Or, a member must receive an
authorization to do most types of surgery. There are various types of authorizations. |
| Authorization Status Type |
This indicates whether the authorization has been approved, pended or denied. There
are various detailed breakdowns within each of these categories. For example, types of
denial statuses are non-covered benefit, does not meet criteria. Example: A- Approved by
nurse, B - review Started but not completed, C- In appeal, D - Denied - use only if
category of denial cannot be determined or specific code is not defined Management help
determine and implement the authorization rules. |
| Authorization Type |
Groupings of medical categories that are used for reporting purposes and utilization
management purposes. Example: consulting out-of-area, detoxification outpatient, home
health nursing. Nurses have final approval over the granting of authorizations. |
| Authorized Diagnosis |
These codes indicate the specific medical diagnosis for which the authorization
applies. |
| Authorized Procedure |
Procedure codes which have been authorized to be performed for a member. An
authorization can approve more than one procedure, and an authorized visit can involve the
completion of more than one procedure. |
| Authorized Visit |
A visit to a provider or facility that has been authorized for a member. More than one
visit can be authorized. |
| Code Category |
The list of categories that a procedure code may be associated with. For example,
radiology, heart surgery, etc. |
| Diagnosis Code |
The decision reached from the process of determining by examination the nature and
circumstances of a diseased condition. In most cases, this determination is decided on by
the attending physician. Example; Pneumonia; Broken Arm |
| Employee |
A person who is employed by the company. |
| Facility Authorization |
The facility where the procedure has been authorized to be performed. This facility
must be one which the provider of service is affiliated with. |
| Group Master |
People grouped based on common characteristics for the purpose of purchasing a product
offering and the relationships that the different groups have. (i.e. Sears has Sears
Retailers, Discover, etc.) At the point of selling a contract to a group, this file is
attached to the Group file in the legacy system. Example: Novell; Utah Auto Dealers
Association; |
| Member |
The individual that health plan benefits are attached to. For example, an employee of
an employer group that Health Plans has a contract with. This person is known as the
subscriber for the benefits. This subscriber can also have related people which are
covered by their benefits. These members are known as dependents (of the subscriber).
Every benefit is attached to one subscriber, and that subscriber may or may not have
dependents which are also covered by the benefits. |
| Member Authorization History |
Information about the authorizations that a member has had. A member can be authorized
for a variety of things, ranging from authorization to see a specialist to getting
permission to enter a hospital. Example: A member sees their PCP and gets authorized to
see a heart specialist for more tests. |
| Place Of Service |
A valid place where a provider plan type contract is authorized to have services
performed. Place of Service codes are national HCFA codes. For example, ER, inpatient,
outpatient. Example: Emergency Room; Inpatient; |
| Procedure Code |
A code indicating the procedure that was performed on the claim. |
| Provider Person |
A person that supplies a health care service. For most of the company, this refers to
a doctor. A provider can be a nurse, a pharmacist, a social worker or a chiropractor. |
| Provider Plan Type |
A plan type that a provider has contracted with Health Plans for. |
| Service Reason |
A code indicating the type of service for the claim detail line. This is a field on
the HCFA 1500 claim form. Example: Outpatient; Inpatient; General Medicine; Emergency Room
Submitted by the provider on the HCFA 1500 claim form. This needs to be at the claim
detail line level, and not the claim header level. |
| Service Type |
The list of valid code types. For example, DRG, HCPC, CPT etc. |
| Specific Procedure Code |
A list of valid procedures that can be associated with a particular pricing schedule.
These codes include CBT codes, HCPC codes, DRG codes, and codes we develop. |
| Utilization Nurse |
The person, usually a nurse, managing the utilization of members. Utilization nurses
are the professionals who distribute and approve authorizations. |
