Claims

Stores the enterprise-level master person or entity identifier linked to a prior authorization record, enabling consistent identification across multiple health plan systems. Used in utilization management data integration to reconcile authorization records across claims, enrollment, and clinical platforms.

Defines the upper limit of approved units, visits, days, or dollar amounts permitted under a prior authorization. Used in utilization management and claims adjudication to enforce approval boundaries and deny claims that exceed the quantity or value approved during the pre-authorization review process.

Captures the middle name or initial of the member associated with a prior authorization request. Used in utilization management systems to disambiguate members with similar first and last names, ensuring accurate matching to enrollment records and preventing authorization assignment errors.

Defines the lower threshold of units, visits, days, or dollar amounts required to satisfy a prior authorization requirement. Used in utilization management workflows to establish baseline service expectations and flag claims that fall below the clinically approved service quantity during adjudication.

Records the mobile phone number of the member or contact person associated with a prior authorization request. Used by utilization management staff to communicate authorization decisions, request additional clinical documentation, and send real-time status notifications directly to the member or care coordinator.

Identifies the user ID or system account responsible for the most recent update to a prior authorization record. Used in utilization management audit trails to track accountability, support compliance reviews, and investigate changes to authorization decisions or clinical criteria applied during review.

The timestamp recording the most recent update to a prior authorization record in payer, EHR, and utilization management systems, including changes to status, approved units, or clinical criteria. Used by data engineers to implement incremental data loads, track authorization lifecycle changes, and support audit trail requirements in compliance and claims analytics pipelines.

Records the exact timestamp when a prior authorization record was last updated in the utilization management system. Used in audit logging, workflow tracking, and compliance reporting to document when authorization decisions, clinical criteria, or approval parameters were changed and by which process.

A human-readable display label assigned to a prior authorization type or record in payer, EHR, and utilization management systems, often corresponding to a service category or program name. Used by data engineers to populate authorization reference tables, support user-facing reporting interfaces, and map authorization records to clinical service taxonomies in analytics pipelines.

Unique alphanumeric business identifier assigned to a prior authorization request, used for cross-system referencing between payer UM platforms, provider EHR systems, pharmacy PBM adjudication engines, and claims processing workflows. Required on 837 transactions for authorization validation.

Captures the date when the member's symptoms or medical condition first began, as reported on the prior authorization request. Used by clinical reviewers in utilization management to assess medical necessity, determine appropriate level of care, and evaluate whether the requested service aligns with the condition timeline.

The blood oxygen level for a service pre-approval. Used in healthcare data management and clinical workflows. This field is commonly used in electronic health records (EHR), healthcare information systems (HIS), and clinical data warehouses for authorization management and reporting.

Records the actual dollar amount paid against a prior authorization after claims adjudication is complete. Used in utilization management and financial reporting to track spend against approved authorization limits, monitor budget consumption, and reconcile payments with the approved authorization value.

Records the date on which payment was issued for services rendered under a prior authorization. Used in utilization management financial reconciliation to confirm that approved services were paid within contractual timelines and to match remittance data against the original authorization approval.

Foreign key reference linking a child authorization record to its originating parent authorization in UM systems that support hierarchical approval structures, such as episode-of-care groupings, multi-service approvals, or amendment chains tracked within payer adjudication platforms.

Captures the transaction dollar value associated with a payment linked to a prior authorization. Used in utilization management and claims financial workflows to track cumulative spend against authorized service limits, supporting cost monitoring and ensuring payments do not exceed approved authorization thresholds.

Indicates the current payment processing state for services rendered under a prior authorization, such as pending, paid, or denied. Used in utilization management and claims adjudication workflows to monitor financial resolution of approved services and identify authorizations with outstanding or rejected payment transactions.

Numeric percentage value associated with a prior authorization, representing partial approval thresholds, benefit coverage rates, or cost-sharing splits applied during UM adjudication in payer systems, PBM platforms, and managed care authorization workflows for financial calculations.

Defined date range during which an approved prior authorization remains clinically and administratively valid within payer UM systems, EHR platforms, and claims adjudication engines. Governs service eligibility windows and is validated against claim service dates on 837 transactions.

Telephone contact number recorded on a prior authorization record in UM platforms, representing the provider office, referring facility, or payer UM department contact used for real-time authorization inquiries, peer-to-peer review scheduling, and outbound notification workflows.