Behavioral

PBM and payer-enforced protocol requiring members to try and fail one or more preferred, lower-cost medications before a higher-cost drug is approved for coverage. Stored in prior authorization and formulary management systems; data engineers use step therapy edits to track override rates, compliance, and formulary exception workflows.

Class of older antidepressant medications, including amitriptyline and nortriptyline, identified by drug class codes in PBM formulary and pharmacy claims systems. Data engineers use TCA classification to support medication adherence analysis, drug utilization review, and clinical quality measure reporting across EHR and pharmacy datasets.

An indicator showing that an adolescent patient was screened for behavioral health concerns, such as depression or substance use, during a well-care or primary care visit, supporting pediatric quality measures focused on early identification of behavioral health needs.

The numeric score typically ranging from 0 to 10 resulting from administration of the Adverse Childhood Experiences questionnaire, which screens for exposure to childhood trauma categories such as abuse, neglect, and household dysfunction. Higher ACE scores are strongly correlated with adult behavioral health and chronic disease risk, making this a key field in trauma-informed care models.

An indicator showing that a member left an inpatient behavioral health or substance use treatment facility against the recommendation of the treating clinical team, prior to completion of the planned course of treatment. AMA discharges are associated with significantly elevated readmission and relapse risk and are tracked as a key clinical quality signal.

An indicator corresponding to the NCQA Antidepressant Medication Management HEDIS measure, showing whether a member newly diagnosed with major depressive disorder and started on an antidepressant remained on the medication for both an acute treatment phase and a continuation treatment phase as clinically recommended.

A calculated adherence score commonly derived using proportion of days covered methodology, measuring how consistently a member with a serious mental illness diagnosis fills and takes prescribed antipsychotic medication, a strong predictor of relapse and hospitalization risk.

The total number of weekly or monthly applied behavior analysis treatment hours authorized for a member, typically a child with autism spectrum disorder, used to track utilization against authorization limits and support provider capacity planning for this intensive hours-based treatment modality.

An indicator showing that a member is enrolled in an Assertive Community Treatment program, an evidence-based team-delivered model providing intensive community-based services to individuals with serious mental illness who are at high risk of hospitalization or homelessness without intensive support.

The total number of behavioral health visits or sessions approved under a specific prior authorization, used to track utilization against the authorized limit and trigger reauthorization workflows as a member approaches the visit cap. This field is essential for managed behavioral health organizations monitoring concurrent review timing.

An indicator showing that a member has a documented autism spectrum disorder diagnosis, used to drive eligibility determination for applied behavior analysis services and other autism-specific behavioral health benefits mandated under most state insurance laws.

A reference number assigned by a payer or managed behavioral health organization when prior authorization is granted for a specific course of behavioral health treatment, including authorized visit counts, level of care, and date ranges. This number must appear on subsequent claims for the authorized services to be considered for payment without additional medical necessity review.

A count of inpatient psychiatric or residential treatment bed days utilized by a member or population during a defined reporting period, used in facility capacity planning, payer utilization trend analysis, and bed-day-based reimbursement models common in state behavioral health systems.

A flag identifying that a member's behavioral health benefit is administered separately from their medical benefit by a distinct managed behavioral health organization, as opposed to an integrated benefit design managed by a single payer, a structural distinction that significantly affects claims routing and data integration architecture.

A code identifying the specific reason a behavioral health claim was denied during adjudication, such as lack of medical necessity documentation, missing prior authorization, or level-of-care mismatch, used in denial trend analysis and provider education programs targeting reduction of avoidable denials.

A status code reflecting a member's current consent posture regarding sharing of behavioral health treatment information across providers and systems, accounting for the layered consent requirements under HIPAA and where applicable 42 CFR Part 2 for substance use records.

A unique identifier assigned to a single behavioral health visit, session, or service event recorded within a patient's treatment episode. This identifier links all clinical documentation, billing records, and outcome measurements associated with that specific encounter, and is distinct from the broader episode-of-care identifier that may span multiple encounters across a treatment course. Used in behavioral health data warehouses to join encounter-level facts to claims, clinical notes, and quality measure calculations.

A code identifying the originating clinical or billing system from which a behavioral health encounter record was extracted, used in data lineage tracking and reconciliation across multiple electronic health record and practice management systems feeding a unified behavioral health data warehouse.

A unique identifier representing a continuous course of behavioral health treatment for a single condition or presenting problem, spanning from initial assessment through discharge or treatment completion. An episode may contain multiple encounters across different levels of care, such as a member who progresses from inpatient psychiatric admission to partial hospitalization to outpatient therapy. Episode-level identifiers are critical for measuring continuity of care and calculating readmission rates.

A code classifying the subject matter of a formal member grievance related to behavioral health services, such as access delays, denial of services, or quality of care concerns, used in regulatory grievance reporting and complaint trend analysis.