| Term | Definition |
|---|---|
| Adjudication | The process by which insurance payers review and determine the eligibility, coverage, and reimbursement for submitted claims, including prior authorization requests, based on contractual agreements and established criteria. |
| Adjudication Service | A system or service provided by insurance payers that enables the review and processing of claims, including prior authorization requests, to determine eligibility, coverage, and reimbursement according to established guidelines and contractual agreements. Note: this may be fully automated or involved human review. |
| Card (in the context of CDS Hooks repose) |
Guidance returned from a CDS Service, representing recommendations or suggestions for presentation within a CDS Client. The content is meant to be human-readable and not directly actionable by the client system, unlike System Actions |
| CMS-0057 | The CMS Interoperability and Prior Authorization Final Rule mandating standardized APIs for electronic prior authorization and data exchange. |
| CPT Code (Current Procedural Terminology) | A standardized code set used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies, and accreditation organizations. Maintained by the AMA’s CPT Editorial Panel, CPT codes ensure clinically valid, up-to-date codes reflecting current practice across public and private health insurance programs. |
| CDS Client | A component of a CDS Hook. Typically, an EHR or other clinical system that consumes decision support guidance in the form of cards and system actions |
| CDS Hooks | A specification describing RESTful APIs and interactions to integrate Clinical Decision Support (CDS) between CDS Clients (e.g., EHRs) and CDS Services. All data is transmitted as JSON over secure HTTPS channels. |
| CDS Service | A component of a CDS Hook. Accepts requests containing patient information and returns decision support guidance in the form of cards. |
| CRD (Coverage Requirements Discovery) | Defines a workflow allowing payers to provide information about coverage requirements to healthcare providers at the point of care. CRD uses CDS Hooks to query payers; when requirements exist, CDS cards and/or system actions are returned with guidance. |
| CRD Clients | Systems that healthcare providers use at the point of care, such as EMRs, pharmacy systems, and other clinical or administrative systems. These clients consume coverage requirements information to support care planning. |
| CRD Services (or Servers) | Systems operated by payers to share coverage rules and requirements with healthcare providers. A CRD Service may provide coverage information for one or more insurance plans. |
| DTR (Documentation Templates and Rules) | Defines a workflow that provides templates and rules to ensure prior authorization requests include all necessary clinical documentation for review and approval. |
| HIPAA (Health Insurance Portability and Accountability Act) | U.S. law that sets standards for the protection and privacy of patient health information. |
| Interoperability | The ability of different healthcare systems to exchange, interpret, and use data consistently. |
| PA (Prior Authorization) | The process by which healthcare providers obtain approval from insurance payers before certain medical services, procedures, or medications can be provided to patients. |
| PAS (Prior Authorization Submission) | Defines a workflow to submit, track, update, and cancel prior authorization requests between providers and payers |
| Payer | An organization that provides health insurance coverage and reimburses healthcare providers for services rendered to covered individuals. |
| Prior Authorization Request | A formal submission by a healthcare provider to an insurance payer, requesting approval for a specific medical service, procedure, or medication before it is provided to a patient. |
| Provider | A healthcare professional or organization that delivers medical services to patients. |
| System Actions (in the context of CDS Hooks repose) |
Guidance returned from a CDS Service, representing specific data updates which the CDS Client can choose to apply (e.g. adding an extension element to a ServiceRequest resource). The content is meant to be machine-readable, unlike Cards |
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