Healthcare operations glossary

The HIPAA electronic remittance advice transaction. It carries claim payment amounts, adjustments, and the reason and remark codes that explain them.

The HIPAA electronic transaction for professional healthcare claims. Payers publish their own implementation requirements on top of the standard, so a claim that satisfies one payer can still be rejected by another.

Average Wholesale Price. A published list benchmark referenced in many reimbursement formulas. It reflects neither the price a pharmacy paid nor the price a payer settles at.

Brand Effective Rate. A PBM contract term expressing a guaranteed aggregate rate across brand claims. Which claims count, over what period, and how a shortfall is settled are defined by the agreement rather than by the term.

An internal, source-independent representation of an operational fact, carrying its provenance, so downstream workflows do not depend on any one vendor’s field shape.

Electronic Product Code Information Services. A GS1 standard for sharing supply-chain events: what moved, where it was, when it happened, and why.

Fast Healthcare Interoperability Resources. An HL7 standard for exchanging healthcare data over REST APIs. Implementation guides narrow its options for a specific use case.

Generic Effective Rate. A PBM contract term expressing a guaranteed aggregate rate across generic claims. Read the agreement for the claim population, the measurement period, and the reconciliation method.

National Average Drug Acquisition Cost. A CMS reference derived from a survey of retail pharmacy invoice prices. It is a national average and will differ from what any single pharmacy paid.

National Council for Prescription Drug Programs. The standards body whose transaction standards carry pharmacy claims between pharmacies and payers.

Where a record came from, when it was received, and every change made to it since. Provenance is what lets a reviewer trust a figure they did not produce themselves.