Glossary

An appeal is a formal request for review of a denied prior authorization. The healthcare provider or patient may appeal if they believe the denial was incorrect or unjust. 

The appeals process is the formal process by which healthcare providers or patients can challenge a denial of prior authorization or coverage decision made by the insurance company. 

Authorization is the approval granted by a healthcare insurance plan for a specific service, treatment, or referral. Some referrals may require prior authorization for coverage.

Clinical Data Exchange (CDex) is a standardized way to move clinical data from Electronic Health Records (EHRs) to other parties, such as patients, payers, and other providers. CDex is a payload for the CMS Access APIs and Prior Authorization API.

Clinical Review is the process of assessing the medical necessity and appropriateness of a requested healthcare service, often conducted by medical professionals employed by the insurance carrier.

Closed-loop referral is a referral system that includes communication and feedback loops between the referring provider and the specialist, ensuring coordination of care and follow-up information.

The Centers for Medicare & Medicaid Services (CMS) released the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) on January 17, 2024. This final rule emphasizes the need to improve health information exchange to achieve appropriate and necessary access to health records for patients, healthcare providers, and payers. This final rule also focuses on efforts to improve prior authorization processes through policies and technology to help ensure that patients remain at the center of their care.

A diagnostic code is a numerical code used to represent specific medical diagnoses, often according to the International Classification of Diseases (ICD) coding system.

EDI 278 is the transaction request used to submit authorization and referral requests electronically.

EDI 278I is the transaction used to check the status of previously submitted authorizations and notifications.

EDI 278N is the exchange of admission notification data between an inpatient facility and insurers.

Electronic Health Record is an electronic version of a patient’s medical history.

Electronic Prior Authorization is the digital submission and processing of prior authorization requests, which can streamline the approval process and reduce paperwork.

Expedited Prior Authorization is an accelerated process for obtaining approval for urgent or life-threatening medical services, typically with a quicker turnaround time.

The Fast Healthcare Interoperability Resources (FHIR) 1 standard defines how healthcare information can be exchanged between different computer systems regardless of how it is stored in those systems.

A Formulary is a list of prescription drugs covered by a health insurance plan and information on their tier or cost-sharing level. Prior authorization may be required for medications not on the formulary.

FQHCs are primary care clinics that receive federal funds to provide healthcare services to underserved communities. They operate in both rural and urban areas designated as shortage areas.

Gold Carding is when payers waive prior authorization on services and prescriptions ordered by providers with a proven track record of prior authorization approvals.

Green Lighting uses real-time, physician and code-specific data to avoid prior authorization requirements.

A healthcare provider is a person or organization that provides medical services or care to patients. This can include hospitals, doctors, specialists, and other healthcare professionals.

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law passed in 1996 that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge.

HIPAA compliance refers to the rules and policies that healthcare organizations must implement to protect the privacy, security, and integrity of protected health information.

HL7 FHIR is the Fast Healthcare Interoperability Resources 1 standard defines how healthcare information can be exchanged between different computer systems regardless of how it is stored in those systems.

A HMO is a type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage.

Healthcare providers or services that are part of the contracted network of a specific insurance plan. Referring patients to in-network providers may impact coverage and out-of-pocket costs.

Interoperability refers to the ability of applications to exchange and make use of information.

Medical Authorization is when a service prescribed by the physician is not covered by the patient’s insurance company, the PCP must obtain medical authorization. The physician needs to contact the insurance company or fill in the required forms to explain why the prescribed service is required and the supporting clinical factors.

A medical necessity is the determination that a healthcare service or treatment is required to prevent, diagnose, or treat a medical condition and is consistent with generally accepted medical standards.

A network is a group of healthcare providers, including primary care physicians and specialists, contracted with an insurance plan or healthcare organization to provide services to covered individuals.

Notice of Action (NOA) is a letter that health plans must send to patients when a requested service has been denied.

Notice of Admission is a one-time notification for a series of home health periods of care.

The Office of the National Coordinator for Health Information Technology (ONC) is at the forefront of the administration’s health IT efforts and is a resource to the entire health system to support the adoption of health information technology and the promotion of nationwide, standards-based health information exchange to improve health care. ONC is the principal federal entity charged with coordinating nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information.

Out-of-Network are healthcare providers or services that are not part of the contracted network of a specific insurance plan. Referring patients to out-of-network providers may result in higher costs for the patient.

Prior Authorization Support (PAS) is the administrative process for obtaining approvals. PAS typically involves submitting detailed information about the patient's medical condition and proposed treatment to the payer for review. PAS aims to ensure that the requested healthcare services are medically necessary and appropriate while also managing costs and ensuring compliance with insurance policies.

A payer is a person, organization, or entity that pays for the care services administered by a healthcare provider. This most often refers to health insurance companies, which provide people with insurance that offers cost coverage and reimbursements for medical services. This could be a private insurance company or a government program.

Often referred to as a health plan, Payer plans are offered by insurance companies to assist in the cost and reimbursements for medical services.

Payer portals allow healthcare organizations to pull prior authorizations and check the status of referrals.

A payer web form is an online form used to submit prior authorizations outside of electronic fax or portal submission.

Peer-to-Peer Review is a utilization review process typically associated with a prior authorization denial whereby a conversation is requested between the requesting provider and a payer medical director to discuss medical necessity.

A POS plan is a type of managed-care health insurance plan that provides different benefits depending on whether the policyholder uses in-network or out-of-network healthcare providers.

A preferred provider organization (PPO) is a health insurance plan for individuals and families. PPOs involve networks that are made up of contracted medical professionals and health insurance companies. Healthcare facilities and practitioners, known as preferred providers, offer services to the insurer's plan policyholders at reduced rates.

Pre-certification is a process similar to prior authorization, whereby a request for approval for a service is performed without the need to verify medical necessity; typically entails verifying that a service is a covered benefit with a contracted, in-network provider and at an in-network facility.

A Primary Care Physician is the healthcare provider who serves as the patient's main point of contact for general health concerns and coordinates overall care, including making referrals to specialists when needed. 

Prior authorization—sometimes called pre-authorization or pre-certification—is a health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage. Prior authorization is a formal request made by the medical provider (before offering a medical service) seeking authorization from the insurance company to proceed with a medical service. Authorizations can be sought for tests, surgeries, prescriptions, and other medical services. 

A referral is an order from your PCP to see a specialist or receive certain medical services from some providers. Many HMOs require a referral before a patient gets medical care from anyone other than the primary care provider.

Referral authorization is the requirement of a referral from your primary care doctor for most other medical services.

A specialist is a healthcare provider with expertise in a specific area of medicine or healthcare, such as a cardiologist, dermatologist, or orthopedic surgeon.

A Third-Party Administrator is an administrative services provider that delivers support for self-insured health plans.

The evaluation and management of healthcare services to ensure they are medically necessary and cost-effective. Prior authorization and referral management are components of utilization management.