Domain Glossary
Terms as used in HOMER. Where the official user guide glossary defines a term (User Guide ch. 27), that definition leads — it is the business's own vocabulary; the data-model mapping from the reconstructed schema follows in parentheses. Terms marked "(claimspeak)" are flagged by the guide as claims-floor jargon.
| Term | Meaning |
|---|---|
| 1099-NEC | IRS form for provider payment reporting; produced for vendors (print_1099s). See Funding. |
| Accum(ulator) | Running totals per member/family — deductible, out-of-pocket, benefit maxima (member_accums). See Claims. |
| Adjudication | Applying benefit rules (benefit_rules) to a claim to determine payable amounts, member responsibility, and denials. See Claims. |
| APS | Attending Physician Statement, used for proof of good health. (User Guide ch. 27) |
| Authorization | Controls which care giver a member may visit as well as what service they may have (claimspeak). (User Guide ch. 27) (um_cases, um_services) See UM & Case Management. |
| Check run | A batch that turns payable claims into printed checks and register entries. See Funding. |
| Claim | A request for payment for services (claims header, claim_lines service lines, claim_entries entry/adjudication records; claims carry a 17-char claim_id). See Claims. |
| Client Master Group | The highest-level group in a client's group structure, under which members may transfer between sub-groups without changing member numbers. (User Guide ch. 27) (groups.master_group_id) See Groups & Plans. |
| COB | Coordination of Benefits — information used for enrolling dependents (User Guide ch. 27); operationally, determining payment order when other insurance exists (coord_of_bens, claim_other_ins_infos). See COB & Pre-Ex. |
| COBRA | Continuation coverage after qualifying events; HOMER produces notices and bills participants (cobra_letters). See COBRA. |
| Coinsurance | Sharing of costs between patients and plans; typically a percentage. (User Guide ch. 27) |
| Copay | A flat dollar amount split between member and provider. (User Guide ch. 27) |
| Coverage | A benefit that a person can elect. (User Guide ch. 27) (election_coverages) See Enrollment. |
| DataWindow | PowerBuilder's data-bound UI/report object; in this documentation, the concrete definition of a screen area or report including its SQL. See As-Is Architecture. |
| Degree of Care Provider | Directive to change dollars based on what type of person performs the service; part of Pricing Rules. (User Guide ch. 27) (pricing_rules) |
| Dependent | A member who can receive coverage through a subscriber. (User Guide ch. 27) (dep_member_sys_key columns) |
| Differential | The difference in the coinsurance (amount or limit) between two benefit packages; see Steerage. (User Guide ch. 27) |
| Disenrollment | HMO term for the action of terminating a person from a plan. (User Guide ch. 27) |
| EDI | Electronic Data Interface — data transmitted on magnetic media rather than manually typed into the system by a person. (User Guide ch. 27) See Integrations. |
| Effective | Describes the fact that a person is covered under a plan. (User Guide ch. 27) |
| Election | A member's chosen enrollment in a plan option for a period (elections, election_coverages). See Enrollment. |
| Eligibility | A member's date-bounded right to coverage under a group (member_eligibilities). See Enrollment. |
| Eligible | Describes the fact that a person can be covered under a plan — contrast Effective, which means the person is covered. (User Guide ch. 27) |
| Employer Copy | A copy of the EOB sent to the group (client). RA copies are not sent to the employer; an Employer Copy never has a check attached; HOMER can enable/disable its printing; it carries the address of the employee for whom the original EOB was produced. (User Guide ch. 27) |
| Enrollment | HMO term for the action of adding a person to a plan. (User Guide ch. 27) |
| EOB | Explanation of Benefits form — document explaining benefits received by or denied to a member when the member is the payee. EOBs may have checks attached or may be zero-dollar payments (also known as worksheets). (User Guide ch. 27) See Reports. |
| EOB Copy | Compiles all the RA information for a specific member for a specific check run, detailing payments sent to vendors on the member's behalf. Never has a check attached; produced for every payment sent to a vendor. (User Guide ch. 27) |
| Examiner | Claims staff member who processes claims (claim_examiner_userid). See Claims. |
| FSA | Flexible Spending Account. (User Guide ch. 27) |
| Funding | Moving client money to pay adjudicated claims; producing checks (fund_register, fundtrans, check runs). See Funding. |
| Group | An entity offering coverage to its members (User Guide ch. 27) — in HOMER, an employer client whose self-funded benefit plan the TPA administers (groups, keyed by group_id; groups can roll up to a master_group_id). See Groups & Plans. |
| HCN | Health Care Network; may include HMOs and PPOs. (User Guide ch. 27) |
| HIPAA | Health Insurance Portability Act of 1996. (User Guide ch. 27) |
| HMO | Health Maintenance Organization. (User Guide ch. 27) |
| MDR | Medical Data Research Corp. — provider of the UCR and R&C tables. (User Guide ch. 27) |
| Member | A person who has coverage under a group; a person may be a member of more than one group. (User Guide ch. 27) (members, keyed by member_sys_key; member_id is the external identifier) See Enrollment. |
| MVA | Motor Vehicle Accident. (User Guide ch. 27) (accident/subrogation handling) |
| OON | Out-of-network expense (claimspeak). (User Guide ch. 27) |
| OOP | Out-of-pocket expense; typically refers to PPO services (claimspeak). (User Guide ch. 27) |
| OV | Office visit (claimspeak). (User Guide ch. 27) |
| PBM | Pharmacy Benefit Manager (PCS/Caremark) — HOMER exchanges eligibility and claim files (drug_covr_*_trans, caremark_edi_table). See Drug Plans. |
| PCP | Primary care physician; an HMO-specific requirement. A person may select multiple PCPs. (User Guide ch. 27) |
| Person | A unique individual in the system, independent of any plan membership, company membership, or coverage. (User Guide ch. 27) |
| Plan | A description of the options, such as benefits, of a Group. (User Guide ch. 27) See Groups & Plans. |
| POGH | Proof of good health. (User Guide ch. 27) |
| POS | Place of service (claimspeak). (User Guide ch. 27) |
| PPO / Repricing | Preferred Provider Organization (User Guide ch. 27); repricing is the application of network discounts to billed charges (claims_reprice_info, pricing_rules, provider fee schedules). See Providers. |
| Pre-cert | The set of services that require pre-certification before beginning. (User Guide ch. 27) See UM & Case Management. |
| Pre-ex | Pre-existing-condition limitation investigation (preex module). See COB & Pre-Ex. |
| Provider | Any individual or other entity that provides medical services to a member. (User Guide ch. 27) See Providers. |
| QMCSO | Qualified Medical Child Support Orders. (User Guide ch. 27) See Enrollment. |
| RA | Remittance Advice form — document explaining payment for services provided to a member when the vendor is the payee. RAs contain all the payments for members of a specific group (rather than issuing several RAs to the same doctor) and may have checks attached or be zero-dollar worksheets. (User Guide ch. 27) See Reports. |
| RA Copy | A copy of the EOB sent to a vendor; SFPI decided not to produce this document. (User Guide ch. 27) |
| R&C | Reasonable and customary charges — internal standard charges for specified procedures. (User Guide ch. 27) |
| Steerage | The effect one hopes to realize from there being a differential between benefit packages; see Differential. (User Guide ch. 27) |
| Stop-loss | Insurance the employer buys against large claims — specific (per person) and aggregate (whole group) (sl_contracts, group_stoploss_parms). See Stop-Loss. |
| Subscriber | A member who can elect coverage under a group. (User Guide ch. 27) (sub_member_sys_key columns) See Enrollment. |
| TLO | Terminal Liability Option for Stoploss — purchased by a client to extend stop-loss coverage when the plan year changes, the case terminates with SFPI/M3, or carriers are changed. (User Guide ch. 27) |
| TPA | Third-Party Administrator — the company operating HOMER. |
| UB92 | Institutional (hospital) claim form; such claims carry extra data (claims_ub92_info, occurrence/condition/value codes). See Claims. |
| UCR | Usual Customary Reasonable; associated with Adjudication Pricing Rules. (User Guide ch. 27) |
| UM / UR / CM | Utilization Management / Utilization Review / Case Management — pre-certification and managed-care case tracking (um_cases, um_services, um_rules, cm_potentials). See UM & Case Management. |
| Vendor | Entity or person, on a claim, who should be paid, and for whom 1099s must be produced. (User Guide ch. 27) |
| WDI | Weekly disability income. (User Guide ch. 27) |