Reference 0009
Eligibility Authorization Boundary
A quick reference for deciding whether payer evidence belongs to eligibility, authorization requirements, authorization decisions, or claim outcomes.
Use this when a workflow says active coverage but a later claim fails for missing authorization.
Boundary Map
| Lane | Owns | Safe State Examples |
|---|---|---|
| ELG | Eligibility and benefit observations. | active, inactive, unmatched, benefit_returned, ambiguous |
| REQ | Whether a service needs authorization or documentation. | unknown, not_required, required, documentation_required |
| AUT | Payer authorization request and decision. | not_started, submitted, pending, approved, denied, expired |
| CLM | Post-submission claim outcome. | submitted, rejected, denied, paid, adjusted |
Key Invariant
Active eligibility does not answer authorization. It can be true that coverage is active, authorization is required, authorization is missing, and the claim later denies.
Submission Gate
| Eligibility | Requirement | Authorization | Safe Claim Prep |
|---|---|---|---|
| Active | Not required | None | Can proceed to other claim checks. |
| Active | Required | Approved and in scope | Can proceed to other claim checks. |
| Active | Required | Missing or expired | Block and create authorization task. |
| Inactive | Any | Any | Block coverage selection for that service date. |
Source Anchors
- CMS Health Plan Eligibility Benefit Inquiry and Response describes eligibility inquiry/response as information about eligibility and coverage under a health plan.
- CMS Electronic Prior Authorization describes prior authorization requests for medical items and services and mentions coverage and documentation requirements.
- CMS MLN Insurance and Authorization treats prior authorization numbers as payer-assigned values for the current service.
- CMS Electronic Health Care Claims describes claim correction, rejection, and denial pathways after claim submission.