Thrizer Canonical Terms
Last Updated: 2026-04-07 Status: CanonicalPurpose: Use this file to resolve the precise meaning of any Thrizer-specific term or insurance-related concept referenced in a query. Route here when: A question depends on the definition of a term (e.g., “What is Allowed Amount?”). Multiple terms could be confused or need disambiguation (e.g., Provider Fee vs Allowed Amount). A response requires consistent, canonical wording of a concept. A downstream answer depends on understanding a term before applying logic. Do not route here when: The query requires workflows, calculations, eligibility rules, or system behavior. The query asks “how,” “when,” or “why” something happens rather than “what it means.” This file is the single source of truth for terminology only.
Payment Types
Thrizer Pay
A payment type where the client payment at time of service is based on an estimated out-of-pocket responsibility.OON Pay
A payment type where services are processed as out-of-network insurance claims.Self-Pay
A payment type where no insurance claim is submitted.Financial Terms
This file defines terminology only. All financial concept definitions (including Provider Fee, Allowed Amount, Deductible, and Coinsurance) are governed by: → Thrizer Insurance Definitions (Canonical) Routing Rule:- If a query requires meaning or interpretation of a financial insurance concept, route to Thrizer Insurance Definitions.
- This file must not redefine or restate financial calculation concepts.
- Do not duplicate definitions from Insurance Definitions in this file.
- This file may reference financial terms but must not define their calculation logic or behavior.
Estimated Values
Estimated Reimbursement
A predicted insurance payment amount based on available information.This value is not guaranteed.
Estimated Out-of-Pocket Responsibility
A predicted client payment amount for a service.This value is not guaranteed.
Claims
Claim Status
The processing state of an insurance claim.A claim has exactly one status at any given time.
Canonical Values
- Processing
- Investigating
- Approved
- Denied
Claim Result
The outcome of claim processing, including financial components such as reimbursement amount or deductible credit.Reimbursement
The amount paid by an insurance carrier after claim processing.Primary Insurance On File
- Indicates that the client’s insurance has been verified within the Thrizer system.
Eligibility
Eligibility indicates that a client’s insurance is confirmed via benefit check to use Thrizer. Eligibility means the benefit check is usable. It is a binary state. Eligibility does not determine:- coverage details
- reimbursement amounts
- payment type availability
Claim Outcome Type
DefinitionClaim Outcome Type is a normalized classification of the financial result of a processed claim. This field standardizes interpretation across systems and prevents ambiguity between status and financial outcome. Canonical Values:
- Reimbursed
- Applied to Deductible
- Denied
- Claim Status = Approved AND reimbursement > 0 → Reimbursed
- Claim Status = Approved AND reimbursement = 0 AND deductible applied → Applied to Deductible
- Claim Status = Denied → Denied
- “Approved_Applied_To_Deductible” is not a canonical status.
- Deductible application must be represented using:
- Claim Status = Approved
- Claim Outcome Type = Applied to Deductible
Verification States
Usable Benefit Check
A benefit check is usable when benefit information is successfully returned and is sufficient for Thrizer claim workflows and reimbursement estimates.eligibility_verified
eligibility_verified = true when a usable benefit check exists.
This is a pre-claim verification state.
Successful Claim
A successful claim is a processed claim that results in either:- reimbursement, or
- deductible application
coverage_verified
coverage_verified = true when at least one successful claim exists.
This is a post-claim verification state.
Distinction
eligibility_verifiedmust not be used to mean post-claim confirmationcoverage_verifiedmust not be used to mean benefit-check usability