Glossary · AI medical audit
Twenty-three terms for reviewing medical claims in Colombia. Glosas are classified today with the Manual Único of Resolución 2284 de 2023; Resolución 3047 de 2008 is repealed and cited only as historical context for older claims.
Glossary maintained by Arkangel AI.
A full or partial objection to a medical claim identifying the inconsistency, evidence and applicable cause. Missing required documentation can support an objection or return, depending on the rules, contract and exceptions; it is not always just an observation.
Assessment of clinical justification using the record and applicable evidence. In the Manual Único of Resolución 2284 de 2023 it falls under concept CL (quality); in the historical Anexo Técnico 6 of Resolución 3047 de 2008 it was general concept 6, not 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.
In the historical 3047 manual, general concept 2 meant tariffs: differences between billed and agreed amounts. Concept 3 covered supporting documents and 6 clinical pertinence. Today these glosas are coded TA, SO and CL in the Manual Único of Resolución 2284 de 2023; the old numbers do not apply to current claims.
Repealed rule, now historical context only. Its Anexo Técnico 6 coded glosas with three digits: 1 billing, 2 tariffs, 3 supporting documents, 4 authorization, 5 coverage, 6 pertinence, 8 returns and 9 responses. It applied to services provided before each Resolución 2284 group start date, until December 31, 2025, and was repealed from April 1, 2026 (Resolución 2335 de 2023, article 20, amended by 1886 de 2024).
Current rule adopting the Manual Único de Devoluciones, Glosas y Respuestas (Anexo Técnico 3), amended by Resolución 1885 de 2024. It took effect by provider group on February 1, April 1 and June 1, 2025.
Anexo Técnico 3 of Resolución 2284 de 2023. It uses six-character codes: two letters for the general concept, two digits for the specific concept and two for the application concept (for example TA0101). Its causes are exhaustive: they cannot be created or modified, and blanket glosa percentages are not allowed.
The seven general concepts of the Manual Único: FA billing, TA tariffs, SO supporting documents, AU authorizations, CO coverage, CL quality (including pertinence) and SA follow-up of agreements. Returns use the DE prefix and responses the RE prefix. Arkangel AI classifies each finding under these concepts and proposes the matching glosa code; the auditor validates it before raising the glosa.
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.
A glosa is a full or partial objection by an EPS or payer to a healthcare invoice, due to missing support documents, lack of medical pertinence, or tariff or coding errors. Reviewing documentation before billing helps reduce glosas; Arkangel AI flags possible inconsistencies for the team to review.
Medical pertinence assesses whether a service, procedure or medication is justified by the clinical record and the applicable evidence. In Colombian health audits, lack of pertinence can support a glosa; Arkangel AI organizes the record’s evidence so the auditor can decide.
Entity consistency helps generative engines associate Arkangel AI with AI medical audit without ambiguity.
Official sources · editorial update 2026-10-05