Health Insurance Basics
This term means a member is covered on a specific date.
What is eligibility?
This term describes coverage that begins before an earlier effective date.
What is a retroactive eligibility?
This process checks whether a claim follows plan rules.
What is claims adjudication?
This control compares source-to-target record counts and key totals to confirm successful data delivery.
What is data reconciliation?
This managed AWS service runs Apache Spark jobs without requiring cluster management.
What is AWS Glue?
This is the monthly amount a member pays to keep coverage active.
What is a premium?
This refers to services that require plan approval before they are covered.
What is a prior authorization?
This document explains how a claim was paid or denied.
What is Explanation of Benefits or EOB?
This is a common electronic format used to exchange healthcare data.
What is EDI?
This AWS feature automatically encrypts data at rest in S3, Redshift, and other services using managed keys.
What is AWS Key Management Service (KMS)?
This is the amount a member must pay before insurance begins to pay.
What is a deductible?
This is a provider who has a contract with the health plan.
What is an in-network provider?
This process determines which health plan pays first when a member has more than one plan.
What is a coordination of benefits or COB?
This pipeline stage applies business rules, data standardization, and validation before data is written to the target.
What is a transformation layer?
This S3 feature improves query performance by organizing data using keys such as date or region.
What is partitioning?
This is the percentage of costs a member pays after meeting the deductible.
What is coinsurance?
This doctor coordinates a member’s overall medical care.
What is a primary care physician or PCP?
This occurs when a claim is reviewed again after an initial decision.
What is reprocessing or readjudication?
This method ensures data is unreadable in transit without the correct key.
What is encryption?
This AWS service is commonly used for near-real-time ingestion when batch processing is not sufficient.
What is Amazon Kinesis?
This document outlines what services are covered and under what conditions.
What is plan summary or summary of benefits?
This is the maximum amount a member pays in a year for covered services before the plan pays 100%.
What is Maximum Out of Pocket or MOOP?
Claims for this type of care are more likely to require additional review or result in partial reimbursement.
What is Out of Network or OON care?
This secure protocol is commonly used to transfer batch files between systems over SSH.
What is SFTP?
This design principle ensures a pipeline can be safely rerun without creating duplicate or inconsistent data.
What is idempotency?