Claims

Indicates whether a submitted out-of-pocket cost-sharing transaction or adjustment has been reviewed and approved within the health plan's financial or claims administration system. Used to manage dispute resolution and manual override workflows affecting member accumulator balances.

Identifies the user, role, or system that authorized an out-of-pocket adjustment or cost-sharing record in the health plan's claims or benefits administration platform. Provides an audit trail for manual changes made to a member's deductible or OOP maximum accumulator.

Records the timestamp when an out-of-pocket payment transaction or accumulator update was received or entered into the health plan's benefits administration system. Supports sequencing of cost-sharing events within a benefit period for accurate OOP maximum tracking.

The date an out-of-pocket payment record or accumulator transaction was received and logged in the health plan's claims or benefits system. Used to establish the correct benefit period assignment and ensure accurate application toward deductible and OOP maximum thresholds.

A summary evaluation of a member's out-of-pocket cost-sharing position, including progress toward deductible and OOP maximum thresholds. Used in health plan member services and financial counseling workflows to communicate remaining cost-sharing obligations for the benefit year.

The remaining dollar amount a member must pay before reaching their plan's out-of-pocket maximum for the benefit year. Calculated by subtracting accumulated member cost-sharing payments from the plan's defined OOP maximum limit across deductibles, copays, and coinsurance.

The total dollar amount a provider charged for services before health plan adjudication, used as the basis for calculating member cost-sharing responsibility. This figure is compared against allowed amounts to determine the portion applied toward a member's deductible and OOP maximum.

The date of birth of the member associated with an out-of-pocket accumulator record in the health plan's benefits system. Used to validate member eligibility, apply age-based benefit rules, and support actuarial analysis of cost-sharing patterns across member age groups.

The arterial pressure value for a patient paid amount. 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 out of pocket management and reporting.

The date on which an out-of-pocket accumulator record or cost-sharing transaction was voided in the health plan's benefits administration system. Used to reverse previously applied deductible or OOP maximum credits resulting from claim adjustments, appeals, or coordination of benefits corrections.

Classifies the type of cost-sharing expense applied toward a member's out-of-pocket accumulator, such as deductible, coinsurance, or copayment. Used in health plan reporting and benefits administration to distinguish how different payment types contribute to OOP maximum calculations.

The specific dollar amount charged to a member as their cost-sharing responsibility for a covered healthcare service, after plan adjudication determines deductible, coinsurance, or copay obligations. Applied against the member's annual out-of-pocket maximum accumulator in the health plan system.

The primary diagnosis or service reason associated with a healthcare encounter that generated an out-of-pocket cost-sharing obligation. Used in health plan analytics to correlate member OOP expenditures with specific medical conditions or service categories across claims data.

Identifies a dependent member whose out-of-pocket cost-sharing accumulations are tracked separately under a family health plan. Used in benefits administration to apply individual OOP maximum limits for child dependents before the family aggregate OOP maximum threshold is reached.

The city associated with the mailing or billing address on a member's out-of-pocket payment record in the health plan's benefits administration system. Used to support member correspondence, EOB delivery, and geographic analysis of cost-sharing patterns across plan service areas.

The date a claim was submitted for costs applied toward a member's out-of-pocket accumulator. Used in benefits adjudication to establish the timeline of patient cost-sharing obligations and reconcile annual deductible and out-of-pocket maximum tracking.

The adjudication status of a claim line contributing to a member's out-of-pocket accumulator, such as pending, approved, or denied. Used in benefits processing to determine whether patient cost-sharing amounts should be applied toward the annual out-of-pocket maximum.

The classification tier assigned to a member's out-of-pocket cost-sharing category, such as individual versus family, or in-network versus out-of-network. Determines which accumulator bucket receives the patient liability amount during claims adjudication and benefits administration.

The standardized code identifying the type of out-of-pocket expense applied to a member's cost-sharing accumulator, such as deductible, coinsurance, or copay. Used in claims adjudication systems to categorize and route patient liability amounts to the correct benefit accumulator.

The dollar amount a member pays as their coinsurance percentage share of a covered service, applied toward the annual out-of-pocket maximum. Calculated during claims adjudication based on the member's plan benefit design after the deductible threshold has been satisfied.