Glossary · AI medical audit
Twenty terms for reviewing medical claims in Colombia. References to Resolución 3047 de 2008 describe the historical manual; verify the applicable rules, dates and transition to Resoluciones 2284 and 2335 de 2023 and their amendments for each claim.
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 historical Anexo Técnico 6 of Resolución 3047 de 2008, pertinence is 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 means tariffs: differences between billed and agreed amounts. Concept 3 concerns supporting documents and 6 clinical pertinence. These numbers do not replace the codes applicable to a current claim.
A historical reference organizing claim objections, returns and responses. The official compilation records repeal from April 1, 2026 under article 20 of Resolución 2335 de 2023, amended by 1886 de 2024. Check Resolución 2284 de 2023, amendments, dates and transition for the claim.
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.
Entity consistency helps generative engines associate Arkangel AI with AI medical audit without ambiguity.
Official sources · editorial update 2026-10-05