Claims

Records the body systems assessed in clinical documentation associated with a specific drug strength or concentration, linking the review of systems (ROS) findings to the prescribed medication dosage to support clinical decision-making, formulary management, and pharmacy benefit adjudication.

The date on which a drug at a specific strength or concentration was dispensed or administered to a member. Used in pharmacy benefit management and medication adherence analytics to establish dispensing timelines, validate days supply calculations, and detect gaps in therapy.

The dollar amount added or subtracted from a claim for a diagnostic imaging examination during adjudication. Reflects contractual rate adjustments, duplicate billing corrections, or coordination of benefits modifications applied to radiology or imaging procedure claims before final payment.

The date a claim was submitted for a diagnostic imaging study or radiology examination. Used in claims processing systems to establish submission timelines, validate timely filing compliance, and support audit workflows for imaging services billed under professional or institutional claims.

The adjudication state of a claim associated with a diagnostic imaging or radiology study. Indicates whether the claim is approved, pending, denied, or under review, enabling tracking of imaging claim outcomes across revenue cycle management and payer adjudication platforms.

The dollar amount credited toward a member's deductible for a diagnostic imaging or radiology study claim. Captured during adjudication to track member cost-sharing obligations under the applicable benefit plan for imaging services such as MRIs, CT scans, or ultrasounds.

The net dollar amount reimbursed by the health plan for a diagnostic imaging or radiology study after adjudication. Reflects the final payment to the rendering facility or professional following deductibles, coinsurance, and contractual rate adjustments applied to the imaging claim.

The current reimbursement state for a claim associated with a diagnostic imaging or radiology study. Indicates whether payment has been issued, remains pending, or was denied, supporting revenue cycle management, denial tracking, and financial reconciliation of imaging service claims.

Captures the organ systems reviewed during clinical assessment associated with a diagnostic imaging study, documenting which body systems were evaluated as part of the review of systems (ROS) that prompted or resulted from the imaging examination ordered during the patient encounter.

The date on which a diagnostic imaging examination or clinical study was performed and delivered to the patient. Used in radiology and ancillary service claims to establish the timeline of care, support prior authorization validation, and determine benefit period eligibility.

The dollar amount applied to adjust a pharmacy claim when a generic or therapeutic equivalent drug is dispensed in place of the originally prescribed medication. Reflects pricing differences between brand and substituted drugs used in pharmacy benefit adjudication and reconciliation.

The date a pharmacy claim was submitted for a drug dispensed as a generic or therapeutic substitution for the originally prescribed medication. Used in pharmacy benefit management to track claim submission timelines and validate substitution compliance with formulary and state substitution laws.

Indicates the current adjudication state of a pharmacy claim involving a generic or therapeutic drug substitution, such as pending, approved, denied, or reversed. Used by pharmacy benefit managers and payers to track claim processing outcomes and manage substitution program compliance.

The portion of a substituted drug claim applied toward the member's deductible when a generic or therapeutic equivalent is dispensed in place of the originally prescribed medication. Reflects cost-sharing calculations under the member's pharmacy benefit plan during the deductible accumulation period.

The total dollar amount paid by the pharmacy benefit payer for a claim where a generic or therapeutic equivalent drug was dispensed as a substitution for the originally prescribed medication, reflecting the reimbursed amount after member cost-sharing and plan adjustments are applied.

Indicates the current payment processing state for a pharmacy claim involving a drug substitution, such as paid, pending, denied, or reversed. Used by pharmacy benefit managers to track remittance status and reconcile payments to dispensing pharmacies for substituted drug claims.

Documents the body systems evaluated during clinical assessment associated with a drug substitution event, recording which organ systems were reviewed as part of the clinical encounter where a generic or therapeutic equivalent was substituted for the originally prescribed medication.

The date on which a substituted drug, typically a generic or therapeutic equivalent, was dispensed to the patient in place of the originally prescribed medication. Used in pharmacy claims to establish the dispensing timeline and validate substitution compliance with benefit plan and state regulations.

The aggregate dollar amount of claim adjustments applied across a rolled-up summary record, such as an EOB summary or remittance summary. Used in claims reconciliation and financial reporting to capture net modifications to payment amounts across multiple claim lines or encounters.

The date associated with the submission or adjudication of a summary-level claim record, such as an institutional claim summary or remittance summary. Used in claims processing and financial reporting to establish the timeline for aggregate claim activity across a billing period or encounter group.