AI Terminology
AI Terminology Reference Guide
🔹 Product-Specific Terminology
Comprehensive Member View
Synonyms: CMV, CPV, Comprehensive Person View
Definition: A unified view of a member’s profile, tasks, programs, requests, and medical info.
AI Guidance: Treat CMV and CPV as interchangeable.
Member or Person Demographics
Synonyms: Member Profile, Person Profile
Definition: Insurance, provider info, DOB, gender, contact details, enrollment data.
AI Guidance: Used when customer asks for “profile,” “member info,” or “demographics.”
Program Source System
Synonyms: Source
Definition: Origin of a program (e.g., analytics, API, or customer upload).
AI Guidance: Do not confuse with "data source" or "source of truth."
Questionnaires
Synonyms: Assessments (staff), Surveys (member)
Definition: Series of questions for eligibility or care guidance.
AI Guidance: Use context — if completed by care manager = assessment; if by member = survey.
Recently Accessed Members
Synonyms: Recently Viewed Person
Definition: List of recently viewed members for quick access.
AI Guidance: May be referred to as “recents,” “view history.”
Care Management
Synonyms: Care module
Acronym: CM
Definition: Manages member care plans and coordination.
AI Guidance: Clarify CM context if ambiguous.
Utilization Management
Synonyms: UM module
Acronym: UM
Definition: Evaluates medical service necessity.
AI Guidance: Match to “auth,” “review,” “approval” queries.
ACM
Deprecated Term: Ambiguous term that could mean CM or UM.
AI Guidance: Always prompt for clarification if “ACM” is used.
Clinical Intelligence
Synonyms: Rules Engine, CI
Definition: Admin layer for real-time rules, policies, programs, journeys.
AI Guidance: Link to terms like RTR, AAE, AWF.
Auto Workflow Rules
Synonyms: Workflow Automation
Acronym: AWF
Definition: Automates system actions based on logic.
AI Guidance: Separate from decision rules (AAE).
Decision Rules
Synonyms: Auto Approval Rules
Acronym: AAE
Definition: Automatically approves service requests using criteria.
AI Guidance: Specific to UM. Confirm if mentioned generically.
Data Platform
Synonyms: Ingestion Layer, DP
Definition: Central hub for data ingestion (claims, HL7, labs, etc).
AI Guidance: Not synonymous with analytics. Clarify usage.
Analytics
Synonyms: Enrichment, Identification, Stratification
Definition: Identifies member cohorts and risk for outreach.
AI Guidance: Often confused with Data Platform; verify user intent.
Worklist
Synonyms: Homepage, landing page
Definition: Application landing page with recently viewed members/persons, tasks, programs, chats, appointments, etc
AI Guidance: Used to be called "Homepage"
🔹 Core Healthcare Terminology (Payer & Provider)
Prior Authorization
Synonyms: Precertification, Authorization
Acronym: PA
Definition: Pre-approval for medical services.
AI Guidance: Match to status checks, submissions, or appeals.
Appeals & Grievances
Synonyms: A\&G, Member Complaints
Definition: Formal complaints or appeals related to service.
AI Guidance: Differentiate if user is discussing an appeal vs. grievance.
Social Determinants of Health
Synonyms: SDoH, Social Risk Factors
Definition: Social factors affecting health (housing, income, etc.).
AI Guidance: Can trigger outreach or assessments.
Care Plan
Synonyms: Health Plan, Member Plan
Definition: Personalized set of goals and interventions.
AI Guidance: Often shown in CMV or generated post-assessment.
Intervention
Synonyms: Outreach, Action
Definition: Actionable step as part of a care plan.
AI Guidance: Ask if system or user-initiated.
Task
Synonyms: Action Item, Workflow Step
Definition: Assigned activity tied to programs or care plans.
AI Guidance: May be linked to AWF rules or assessments.
Clinical Review
Synonyms: Medical Review
Definition: Staff-led review of clinical necessity or quality.
AI Guidance: Often tied to UM or appeals.
Episode of Care
Synonyms: Case, Treatment Window
Acronym: EoC
Definition: Time-bound treatment experience for a condition.
AI Guidance: Used in bundled payments or reporting.
Risk Stratification
Synonyms: Member Segmentation
Definition: Classifying members by health risk.
AI Guidance: Drives programs, journeys, or campaigns.
Guided Health Journey
Synonyms: Digital Journey
Acronym: GHJ
Definition: Series of steps guiding member care. Interface is a member app.
AI Guidance: Configured via Clinical Intelligence in the journey builder; may be triggered by stratification. Also called a Digital Journey. Interface is a member app.
Campaign
Synonyms: Outreach Program
Definition: Mass engagement based on data insights.
AI Guidance: May be clinical (e.g., flu shots) or social (e.g., food insecurity).
Population Builder
Synonyms: Segment Builder
Definition: Tool to create member cohorts.
AI Guidance: Used in CI for rules, journeys, campaigns.
HL7 / ADT Feed
Synonyms: Admission-Discharge-Transfer
Acronyms: HL7, ADT
Definition: Real-time data feed for clinical events.
AI Guidance: Supports alerts or member flagging.
Provider
Synonyms: Doctor, Specialist, PCP
Definition: Licensed individual or org delivering healthcare.
AI Guidance: Understand difference between “rendering” vs. “referring.”
Person
Synonyms: Patient, Beneficiary, Member
Definition: Person covered by a payer or enrolled in a plan. Used to be called Member.
AI Guidance: Use "member, or Person" in payer context, "patient" in provider context. User Person and Member Interchangable.
🔹 AI Training Notes
Acronym Disambiguation: Always clarify multi-use acronyms (e.g., ACM, CM).
Context Sensitivity: Differentiate terms by user role (e.g., care manager vs. member).
Synonym Recognition: Accept natural variations in client language.
Intent Refinement: Confirm user intent when terms may be ambiguous (e.g., “analytics,” “rules”).