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prior authorization

prior_auth
finance·Updated Jun 23, 2026

Definition

ISO-11179 Definition

The process by which a healthcare provider obtains advance approval from a health insurance payer before delivering specific medical services, procedures, or prescription drugs to ensure the payer will cover the cost of the service. Prior authorization is required by most health plans for elective surgeries, specialty medications, advanced imaging studies, inpatient admissions, and certain outpatient procedures. The prior authorization process involves submitting clinical documentation supporting medical necessity to the payer for review by clinical staff who approve, deny, or request additional information.

CMS and state regulators have increased scrutiny of prior authorization burdens and timelines, with new interoperability rules requiring payers to implement electronic prior authorization APIs. Healthcare data teams build prior authorization tracking systems that monitor authorization status, expiration dates, authorized versus billed services, and authorization denial rates by payer and service type to support clinical workflow efficiency and prevent authorization-related claim denials.

Standard Abbreviation

prior_auth

Category

finance

Production DDL — FACT_CLAIM_TRANSACTION

FACT_CLAIM_TRANSACTION.sql
CREATE OR REPLACE TABLE FACT_CLAIM_TRANSACTION (
    clm_txn_key     INTEGER        NOT NULL  -- surrogate key,
    clm_id          VARCHAR(50)    NOT NULL  -- claim identifier,
    mbr_key         INTEGER        NOT NULL  -- FK to DIM_MEMBER,
    prvdr_key       INTEGER        NOT NULL  -- FK to DIM_PROVIDER,
    clm_typ_cd      VARCHAR(10)              -- claim type code,
    tot_chrg_amt    DECIMAL(18,2)            -- total charged amount,
    tot_alwd_amt    DECIMAL(18,2)            -- total allowed amount,
    tot_pd_amt      DECIMAL(18,2)            -- total paid amount,
    cntrct_adj_amt  DECIMAL(18,2)            -- contractual adjustment,
    denial_ind      CHAR(1)                  -- denial indicator,
    denial_rsn_cd   VARCHAR(10)              -- denial reason code,
    prior_auth_nbr  VARCHAR(30)              -- authorization number,
    clm_lag_days    SMALLINT                 -- claim lag days,
    days_ar         SMALLINT                 -- days in AR,
    load_dt         TIMESTAMP_NTZ  NOT NULL  -- load timestamp
);

Standard Snowflake DDL for the canonical finance table. Convert to BigQuery or Databricks →

Why This Term Matters

Healthcare data terminology is foundational for any data engineer working in this industry. Precise understanding of standard terms enables accurate schema design, reduces downstream data quality issues, and ensures pipelines meet the regulatory and interoperability requirements imposed by HIPAA, HL7 FHIR, and CMS reporting frameworks. Without this foundation, even technically well-built pipelines produce data that fails validation when it reaches payers or regulators.

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