Claims

The reimbursement amount issued to a pharmacy for a dispensed medication after pharmacy benefit adjudication, reflecting negotiated ingredient cost, dispensing fees, and member cost-sharing offsets. Used in pharmacy claims reconciliation and drug spend analytics to track total prescription expenditure by plan and formulary tier.

Indicates the current state of a reimbursement transaction issued to a pharmacy for a dispensed prescription, such as pending, paid, reversed, or adjusted. Used in pharmacy benefit management and accounts payable systems to confirm remittance accuracy, manage pharmacy network payments, and resolve claim payment discrepancies.

The dollar value of a financial modification applied to a claim or encounter associated with a documented patient problem or active diagnosis. Used in claims analytics to track how specific conditions affect reimbursement adjustments, contractual write-offs, and cost-of-care reporting across disease management populations.

The date a claim was submitted that documents or is associated with a specific active patient health problem or chronic condition. Used in claims and care management systems to track service utilization patterns, monitor treatment timelines, and measure gaps in care related to documented diagnoses.

Indicates the current adjudication status of a claim associated with a documented patient problem or active health condition, such as pending, approved, denied, or appealed. Used in claims processing to track reimbursement outcomes tied to specific diagnoses.

The dollar amount applied toward a member's annual deductible for claims linked to a specific documented health problem or diagnosis. Used in benefits adjudication to calculate remaining deductible liability before insurance coverage activates for condition-related services.

The actual dollar amount paid by the insurer or payer for claims associated with a documented patient health problem or diagnosis. Reflects the reimbursement issued after deductibles, copayments, and coinsurance have been applied during claims adjudication.

Indicates the current payment processing stage for claims tied to a documented patient health problem, such as payment pending, payment issued, or payment denied. Used in revenue cycle management to monitor financial resolution of condition-related claim submissions.

Documents the review of body systems conducted during clinical assessment of a specific patient health problem. Captured as part of the medical history and physical examination, this field records which organ systems were evaluated in relation to the presenting condition.

The date a healthcare service was delivered in relation to a documented active problem or diagnosis in EHR problem list records. Used by data engineers to correlate clinical conditions with care events, support chronic disease management analytics, and validate longitudinal patient data in clinical and claims systems.

The date on which a claim was submitted to the payer for a specific medical procedure or surgical intervention. Used in claims management to establish submission timelines, measure adjudication lag, and enforce payer filing deadline compliance.

Indicates the current adjudication status of a claim submitted for a specific medical procedure or intervention, such as received, in process, approved, or denied. Used in claims tracking to monitor reimbursement progress for procedural services billed to insurers.

The dollar amount paid by the insurer or payer for a specific medical procedure or surgical intervention after applying contractual adjustments, deductibles, and member cost-sharing. Reflects net reimbursement issued to the billing provider following claims adjudication.

Indicates the current payment processing stage for a claim associated with a specific medical procedure, such as payment pending, payment issued, or payment withheld. Used in revenue cycle management to track financial resolution of procedure-related claim submissions.

The dollar amount added or subtracted from the original billed charge for a prosthetic device during claims adjudication. Reflects contractual rate adjustments, coordination of benefits modifications, or other payer-applied financial changes to prosthetic device claims.

The date on which a claim was submitted to the payer for a prosthetic device or prosthetic-related service. Used in durable medical equipment claims processing to establish submission timelines and ensure compliance with payer filing deadlines for prosthetics coverage.

Indicates the current adjudication status of a claim submitted for a prosthetic device or prosthetic fitting service, such as pending, approved, or denied. Used in DME claims tracking to monitor reimbursement progress and identify claims requiring follow-up or appeal.

The dollar amount applied toward a member's annual deductible for claims associated with prosthetic devices or fittings. Used in benefits adjudication to determine member cost liability before insurance coverage activates for prosthetic-related services under DME benefits.

The dollar amount paid by the insurer or payer for a prosthetic device or prosthetic service after applying contractual adjustments, deductibles, and member cost-sharing. Reflects net reimbursement issued following adjudication of DME claims for prosthetic equipment.

Indicates the current payment processing stage for a prosthetic device claim, such as payment pending, payment issued, or payment denied. Used in DME revenue cycle management to track financial resolution and identify outstanding reimbursements for prosthetic-related claims.