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Glossary · 23 terms
Health claims glossary: terms used by insurers, TPAs and claims teams.
Plain-English definitions of the terms used in health insurance claims, medical document processing and claims fraud detection, from TPA and pre-authorisation to FWA, ICD-10 and hospital tariffs.
Medically reviewed by Dr. N. S. Santosh Varma, MBBS, FIIM, FIDM, FICCM · Medical Officer, YIRA MedSense · Updated 14 October 2026
Cashless claimClaims adjudicationClient-managed deploymentClinical natural language processingDischarge summaryFacial verificationFraud, waste and abuseHealth maintenance organisationHospital tariffICD-10Intelligent document processingMedical document intelligenceMedical schemeNational List of Essential MedicinesOptical character recognitionPackage ratePre-authorisationPrior-record matchingPrivate medical insuranceReimbursement claimRule-based fraud detectionSpecial investigation unitThird-party administrator
- Cashless claim
- A claim where the insurer or TPA pays the network hospital directly after approving a pre-authorisation, so the patient does not pay the covered amount upfront. Related: how MedSense handles this →
- Claims adjudication
- The process of reviewing a claim against the policy and the medical evidence to decide whether to pay it, how much to pay, or whether to deny it. Related: how MedSense handles this →
- Client-managed deployment
- Running the software inside the customer's own cloud or data centre, so documents stay within the customer's environment. Related: how MedSense handles this →
- Clinical natural language processing (clinical NLP)
- Language technology tuned to medical text that identifies diagnoses, procedures, drug names, lab values and other clinical facts in free text. Related: how MedSense handles this →
- Discharge summary
- The document a hospital issues when a patient leaves, summarising the diagnosis, treatment given, procedures and follow-up advice. It is a core document in most inpatient claims. Related: how MedSense handles this →
- Facial verification (claims)
- Comparing the photo on the insured member's ID with a photo taken at the hospital to confirm that the person treated is the person covered. Related: how MedSense handles this →
- Fraud, waste and abuse (FWA)
- The three ways health insurance money is lost: fraud is intentional deception, waste is unnecessary use or cost, and abuse is practice that leads to improper payment without clear intent. Related: how MedSense handles this →
- Health maintenance organisation (HMO)
- A health plan that provides or arranges care through a network of providers, a common model in Nigeria, the Philippines and the United States. Related: how MedSense handles this →
- Hospital tariff
- A hospital's price list for rooms, procedures and packages, often agreed with each insurer or TPA. Bills are checked against it. Related: how MedSense handles this →
- ICD-10
- The World Health Organization's International Classification of Diseases, 10th revision: a coding system for diagnoses used in claims and health statistics in many countries. Related: how MedSense handles this →
- Intelligent document processing (IDP)
- The use of OCR, machine learning and language models to capture, classify and extract data from documents automatically. Related: how MedSense handles this →
- Medical document intelligence
- Software that reads medical documents such as medical histories, lab reports, discharge summaries and bills, and turns them into structured, checked data for claims and clinical teams. Related: how MedSense handles this →
- Medical scheme
- The name used in South Africa for a non-profit health cover fund that pays members' medical costs. Related: how MedSense handles this →
- National List of Essential Medicines (NLEM)
- India's government list of essential medicines. Recognising NLEM drug names helps claims teams read prescriptions and pharmacy bills accurately. Related: how MedSense handles this →
- Optical character recognition (OCR)
- Technology that converts printed or handwritten text in scans and photos into machine-readable text. Related: how MedSense handles this →
- Package rate
- A fixed, pre-agreed price for a defined treatment or procedure, covering most of the related costs, used to simplify billing and claim checks. Related: how MedSense handles this →
- Pre-authorisation (prior authorisation)
- Approval requested from the insurer or TPA before a planned treatment or hospital admission, based on the doctor's notes and estimated costs. Related: how MedSense handles this →
- Prior-record matching
- Comparing a new claim document with earlier records, field by field, to find reused or duplicated documents. A match is a signal for review, not proof of fraud. Related: how MedSense handles this →
- Private medical insurance (PMI)
- Health insurance bought by individuals or employers to pay for private treatment, a common term in the UK. Related: how MedSense handles this →
- Reimbursement claim
- A claim where the patient pays the hospital first and then submits bills and medical documents to be repaid by the insurer or TPA. Related: how MedSense handles this →
- Rule-based fraud detection
- Checking claims against fixed conditions such as amount limits, frequency limits and invalid code combinations, and flagging claims that break a rule. Related: how MedSense handles this →
- Special investigation unit (SIU)
- The team at an insurer or TPA that investigates suspected fraud cases flagged by claims staff or detection tools. Related: how MedSense handles this →
- Third-party administrator (TPA)
- A company that processes health insurance claims on behalf of insurers or employer plans: it checks documents, approves pre-authorisations, settles claims and manages hospital networks. Related: how MedSense handles this →
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