Glossary · AI medical audit
If you work in medical-claims audit in Colombia, here are the 20 most-confused terms, explained in short, citable definitions. Each entry follows the Colombian regulatory framework and Resolución 3047 de 2008.
Glossary maintained by Arkangel AI.
A full or partial objection that a payer (EPS or insurer) raises against a medical claim when it finds a mismatch between what was billed and what was agreed, documented, or clinically warranted. In Colombia it requires positive evidence of a violation; a missing document is logged as an observation, not a glosa.
The assessment of whether a service, procedure, or medication was warranted for the patient based on the clinical record and the Colombian Ministry of Health practice guidelines. It is the core of the clinical audit domain and the basis of causal 2.
Billing a code of higher complexity or value than the service actually delivered, inflating the charge. It is a typical finding in the financial audit domain.
Splitting into several codes a service that should have been billed as a single bundle, in order to charge more than the integrated rate. Alongside upcoding, it is a central control of the financial layer.
Registros Individuales de Prestación de Servicios de Salud: the structured dataset every provider must report for each encounter. Its completeness and consistency are validated in the administrative audit domain.
Clasificación Única de Procedimientos en Salud: the official Colombian code set that standardizes procedures for billing and reporting. Using the wrong CUPS code triggers claim objections.
A formal claim-objection cause for pertinence, defined in Anexo Técnico 6 of Resolución 3047 de 2008 (e.g. a medication without indication). It belongs to the clinical audit domain.
A Colombian Ministry regulation whose Anexo Técnico 6 defines the seven formal causes under which an insurer can object to a medical claim in Colombia. It is the framework that governs how claim-objection causes are assigned.
Review of a medical claim while the patient is still in care or the service is still open, allowing correction and documentation in real time before the case closes.
Review of a medical claim after the service has been delivered and the invoice filed. This is the usual stage at which claim objections are raised, reconciled, and answered.
The invoice together with its supporting documents (clinical record, authorizations, RIPS) that a provider files to be paid for care. They are the object of the medical-claims audit.
A request by a provider or EPS for reimbursement of services, technologies, or medications not financed by the UPC capitation. Its documentation and pertinence are audited as rigorously as an ordinary claim.
Verification that a claim includes all required supporting documents (authorization, clinical record, RIPS) and that they back what was billed. It is a control of the administrative audit domain.
Justification that the care delivered was required by the patient’s clinical condition, consistent with the evidence and current guidelines. It is closely tied to clinical pertinence.
Translating a patient’s diagnoses and procedures into standardized codes (ICD-10, CUPS) for billing, reporting, and analysis. Correct coding is the basis of a defensible medical claim.
A diagnosis that was present during care but never recorded or coded, which distorts the true complexity of the case and can affect recognition of the service.
Reporting fewer or lower-complexity codes than the services actually delivered, understating the care. It is the reverse of overcoding.
Reporting more or higher-complexity codes than the services actually delivered, overstating the care. It is related to upcoding and is controlled in the financial domain.
Entidad Promotora de Salud: manages member enrollment and insurance coverage in Colombia and, as the payer, audits and objects to providers’ medical claims.
Institución Prestadora de Servicios de Salud: hospitals, clinics, and centers that treat patients, bill for care, and respond to claim objections raised by the EPS or insurer.
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