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EnrollmentProgram or product eligibility check
A coverage must already exist
EligibilityCoverage ValidationCheck whether a stated coverage is inforce - today or at specified time.Coverage detailYes/No
Coverage DiscoveryWhat policies does a person have, e.g. the person doesn't have their card with them.Person detailsCoverages
Specific Benefits DeterminationCheck what classes of benefits the coverage includes, e.g. vision, dental, maternity.Coverage and the type of serviceBenefits, at some level of detail, for those, perhaps more, types of service.
Specific service coverage determinationCheck whether a specified service or product is covered.Coverage and the product or service in questionYes. No, details.
General Benefit determinationObtain the table of benefits and utilization.Coverage detailTable benefits allowances and utilization
Benefit UtilizationTo obtain the benefit categories and the utilizationCoverage detailTable of benefits and utilization
AdjudicationPredeterminationSpecific service reimbursement estimateCheck what the adjudication would be if the service were provided.Coverages and servicesAdjudication results (BUT no promise of benefits).
Prior approvalApproval of servicesSubmission of a suite of services without financial amounts which results in an approval.Coverages and servicesApproval and a reference.
Prior AuthorizationService registration or approvalService approval or notification with costs.Coverages and servicesAdjudication results (limited promise of payment).
Prior Authorization with reservationService registration or approval with reservation of fundsService approval or notification and optionally reservation of funds.Coverages and servicesAdjudication results limited promise or payment.
ClaimSubmission of services performed for consideration under the coverage.ClaimCoverage and service.Adjudication results with payment (can be $0).
Request for pended responses
Provision of supporting information for a previously submitted request
Payment Notification
Payment details, payment reconciliation
Request Processing Status CheckCheck on the processing status of a request.Transaction referenceThe status.