Finance

The actual price a pharmacy pays to procure a drug from a wholesaler or manufacturer, used as a reimbursement basis in PBM and Medicaid FFS claims. Acquisition cost benchmarks such as AAC and WAC appear in drug pricing tables and are referenced during contract validation and reimbursement audits.

A federal subsidy applied in real time to reduce monthly health insurance premiums for eligible enrollees purchasing coverage through ACA Marketplaces. Tracked in enrollment and financial systems to reconcile subsidy amounts against IRS Form 1095-A data and annual tax filings.

Federal legislation requiring continuation health coverage tracking in member enrollment and benefits administration systems. COBRA election dates, premium payment status, and coverage period fields are stored in eligibility databases to support claims adjudication, coordination of benefits, and CMS compliance reporting.

A class of synthetic anti-inflammatory and immunosuppressive medications tracked in pharmacy, PBM, and EHR systems under specific drug classifications. Commonly recorded in medication history, formulary, and prior authorization datasets using RxNorm, NDC, or GPI drug codes.

A federal subsidy program that reduces out-of-pocket costs such as deductibles, copayments, and coinsurance for eligible members enrolled in silver-tier ACA marketplace plans. Captured in member enrollment, benefits configuration, and claims adjudication systems to adjust plan actuarial values.

An IRS-regulated, employer-sponsored benefit account allowing employees to contribute pre-tax wages for eligible medical or dependent care expenses. FSA elections, balances, and transactions are tracked in benefits administration and enrollment systems, and adjudicated in PBM and medical claims platforms to apply FSA payments at point of sale or reimbursement.

A federal law enacted in 1996 establishing national standards for protecting the privacy and security of individually identifiable health information. HIPAA mandates electronic transaction standards including EDI formats for claims, eligibility, and remittance. Violations carry civil and criminal penalties enforced by HHS Office for Civil Rights.

A tax-advantaged savings account available to members enrolled in a High Deductible Health Plan (HDHP), used to pay qualified medical expenses. In PBM and claims systems, HSA eligibility flags influence benefit adjudication logic, cost-sharing calculations, and member accumulator tracking for deductibles and out-of-pocket maximums.

The calculated cost of the active drug product dispensed, derived from a pricing benchmark such as AWP, WAC, or MAC, minus applicable discounts. Captured in PBM claims adjudication systems as ingrd_amt, this field excludes dispensing fees and is a critical component in net drug cost analysis, rebate reconciliation, and formulary financial modeling.

The reimbursement ceiling established by a PBM or health plan for multi-source generic and select brand drugs, used to control pharmacy spend. MAC pricing lists are maintained separately from AWP benchmarks and are applied during claims adjudication in PBM systems to determine the maximum ingredient cost reimbursable to network pharmacies, directly impacting plan and member cost-sharing calculations.

Federal legislation enacted in 1990 that established the Medicaid Drug Rebate Program, mandating drug manufacturers to pay rebates to state Medicaid programs in exchange for coverage. OBRA 90 data impacts PBM and Medicaid claims systems by driving rebate calculation logic, formulary compliance requirements, and drug utilization review standards tracked within state and federal reporting platforms.

A wireless asset and patient tracking technology used in hospital information systems to monitor the real-time location of medical equipment, medications, specimens, and patients. RFID data integrates with EHR and supply chain management platforms to automate inventory control, reduce medication errors, and support regulatory compliance with Joint Commission standards.

A project governance framework used in healthcare data engineering and IT organizations to define role-based ownership for tasks, decisions, and deliverables. In EHR implementations, data warehouse projects, and PBM platform migrations, RACI matrices clarify which stakeholders own execution, approve outcomes, provide subject matter input, or receive status updates, reducing ambiguity in cross-functional data governance workflows.

A 4-digit alphanumeric code required on UB-04 institutional claims and 837I transactions that identifies the type of facility, type of care, and claim frequency. Stored as tob_cd in claims processing systems, this field is critical for routing inpatient, outpatient, and post-acute claims to correct adjudication logic and is used in analytics to segment facility-based utilization and reimbursement data.

The statutory list price at which a drug manufacturer sells a product to wholesalers or direct purchasers, excluding discounts, rebates, or chargebacks. WAC serves as a pricing benchmark in PBM adjudication systems, specialty pharmacy contracting, and government drug pricing transparency reporting, and is referenced in reimbursement calculations where AWP-based pricing is not applicable or available.

The physical or mailing address associated with a healthcare account entity, such as an employer group, provider organization, or member account. Used in EHR, enrollment, and billing systems to route correspondence, claims, and eligibility communications.

A monetary value tied to a specific healthcare account transaction or balance, such as premium amounts in member enrollment systems, claim payment totals in PBM platforms, or billed charges in EHR revenue cycle and accounts receivable workflows.

A calculated metric representing the mean value of financial or utilization data across a healthcare account, such as average monthly premium, average claim cost per member, or average pharmacy spend. Used in PBM, claims analytics, and employer group reporting systems.

The net outstanding financial amount owed or remaining within a healthcare account, including patient responsibility balances in EHR billing systems, FSA or HSA remaining funds in benefits platforms, or unpaid premium balances in member enrollment systems.

A classification label assigned to a healthcare account to group it by type, such as commercial, Medicare, Medicaid, or self-funded in enrollment and claims systems. Used in PBM and payer platforms to apply appropriate benefit rules, pricing tiers, and reporting hierarchies.