Glossary · Foundations
Glossary · FoundationsPrior Authorization
A payer requirement that a service be approved before it is rendered. Without an approved prior auth on file, the claim will deny on submission regardless of medical necessity.
Definition
Prior Authorization.
A payer requirement that a service be approved before it is rendered. Without an approved prior auth on file, the claim will deny on submission regardless of medical necessity.
Sources
Primary references for this entry.
- CAQH CORE Prior Authorization operating rules.
- CMS Medicare Prior Authorization guidance.
Related terms
Other terms in Foundations.
- Foundations
Charge Capture
The process of recording every billable service performed during a patient encounter, ensuring no charges are missed before claim submission.
Open entry - Foundations
Charge Description Master (CDM)
A hospital's complete list of billable items, services, and procedures with associated CPT/HCPCS codes, descriptions, and prices. Updated regularly as codes and prices change.
Open entry - Foundations
Eligibility Verification
The process of confirming, before a patient encounter, that the patient has active insurance coverage and that the planned service is a covered benefit. Conducted via electronic 270/271 transactions to the payer.
Open entry
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