Pharmacy

Captures the monetary or quantitative value associated with an NDC code, such as unit drug cost or reimbursement amount. Used in pharmacy claims adjudication, drug pricing, and formulary management to calculate ingredient costs and reimbursements for dispensed prescription drug products.

Tracks the iteration number of an NDC code record in the drug reference database, identifying which version of drug product information is being applied. Used in pharmacy claims and formulary systems to ensure historical accuracy and support audits of drug pricing or classification changes.

Stores the postal code associated with the manufacturer or labeler linked to an NDC code. Used in pharmacy data systems and drug reference databases to identify the geographic location of the drug labeler, supporting regulatory compliance, drug sourcing verification, and supply chain management.

The fixed dollar amount a member is required to pay at the point of service for nephrology care, including kidney disease treatment and dialysis services. Defined in the member's health plan benefit structure and applied during medical claims adjudication for specialist visits and procedures.

The fixed dollar amount a member owes at the time of service for neurology specialist visits, including care for conditions such as epilepsy, stroke, or multiple sclerosis. Established in the member's health plan benefits and applied during claims adjudication for nervous system specialty services.

A prescription drug covered under a health plan formulary but placed at a higher cost-sharing tier than preferred alternatives due to higher net cost after rebates or less favorable clinical profile compared to preferred tier alternatives within the same therapeutic class. Members using non-preferred drugs pay higher copayments or coinsurance than for preferred alternatives, creating a financial incentive to discuss therapeutic alternatives with their prescriber.

The fixed patient cost-sharing amount associated with a clinical documentation or visit note service encounter. Applied during claims adjudication when a copay is tied to a specific service category documented in the member's health plan benefits, reflecting the member's financial responsibility for that encounter.

The fixed dollar amount a member pays at the point of service for visits rendered by a licensed nurse practitioner or registered nurse. Defined in the member's health plan benefit structure and applied during claims adjudication to reflect patient cost-sharing for nurse-provided healthcare services.

The fixed patient cost-sharing amount applied to obstetric service encounters, including prenatal visits, labor and delivery, and postpartum care. Defined in the member's health plan benefits and used during medical claims adjudication to calculate member financial responsibility for pregnancy-related specialty services.

The fixed dollar amount a member is required to pay for a surgical procedure or operative intervention. Defined within the member's health plan benefit structure and applied during claims adjudication to determine patient cost-sharing obligations for inpatient, outpatient, or ambulatory surgical services.

The fixed patient cost-sharing amount owed at the time of service for ophthalmology specialist visits, including eye exams, glaucoma treatment, and retinal care. Established in the member's health plan benefits and applied during medical claims adjudication for eye specialty encounters and procedures.

A standardized calculation converting different opioid medications and doses to a common unit of morphine milligram equivalents, used to quantify total opioid exposure across multiple prescriptions and prescribers, assess overdose risk, and implement CDC opioid prescribing guideline thresholds. MME calculations are used in pharmacy claims analytics to identify members receiving high-dose opioid prescriptions above 90 MME per day.

A pharmacy utilization pattern indicating a member is receiving opioid prescriptions at doses or from prescriber and pharmacy combinations suggesting potential misuse, diversion, or inadequate pain management oversight, identified through pharmacy claims analysis using CMS and NCQA criteria including morphine milligram equivalent thresholds, multiple prescriber episodes, and multiple pharmacy episodes. Identification triggers care management outreach and prescriber notification.

The fixed patient cost-sharing amount associated with a clinician-ordered service, such as a diagnostic test, imaging study, or laboratory order. Applied during claims adjudication based on the member's health plan benefit structure to determine financial responsibility for ordered ancillary or diagnostic healthcare services.

The fixed dollar amount a member pays at the point of service for orthopedic specialist visits, including care for bone, joint, and musculoskeletal conditions. Defined in the member's health plan benefit structure and applied during medical claims adjudication for orthopedic consultations, procedures, and follow-up care.

The fixed patient cost-sharing amount owed for otolaryngology specialist visits covering ear, nose, and throat conditions. Defined within the member's health plan benefit structure and applied during medical claims adjudication for ENT specialist encounters including hearing, sinus, and upper airway procedures and consultations.

The total direct cost-sharing amount paid by the member for a healthcare service, representing the portion not covered by the health plan. Tracked in claims and member benefit systems to apply toward the annual out-of-pocket maximum accumulator, determining when the plan assumes full financial responsibility for covered services.

The fixed cost-sharing amount defined by the paying insurance entity that a member must contribute at the point of service. Established in payer-specific plan benefit configurations and applied during claims adjudication to calculate the member's financial responsibility, separate from the payer's reimbursement to the rendering provider.

The fixed dollar amount a member or guarantor pays at the point of service for pediatric specialist or primary care visits covering patients typically under 18 years of age. Defined in the member's health plan benefit structure and applied during medical claims adjudication for child healthcare encounters and services.

Unique numeric identifier assigned to a licensed pharmacist within pharmacy management and claims processing systems. Used to track dispensing activity, reconcile billing records, and link pharmacist credentials to prescription transactions across pharmacy benefit and claims platforms.