Glossary
Definitions of healthcare and platform-specific terms used throughout Lilee documentation.
Platform Terms
Lilee
An Operational AI platform for Utilization Management (UM), Care Management (CM), and Post-Decision Workflows in US healthcare.
Ellie
Lilee's built-in AI chat assistant, available from any screen. Ellie performs clinical analysis, policy lookups, code validation, and workflow guidance through natural language conversation and 16 quick actions.
Intake Dashboard
The primary workspace in Lilee where incoming documents are received, classified, and processed.
Detected Workflow
The detail pane that displays AI-extracted fields from a document, organized by document type. Also called the Document Analysis pane.
Clinical Review
The detail pane that shows AI-powered clinical criteria matching results, decision trees, and recommendations based on Medicare coverage policies.
Authorization Review
The detail pane used to prepare and submit authorizations to the connected EHR system.
Quick Action
A pre-built analysis prompt in Ellie that produces a structured, comprehensive response for a specific task (e.g., Prior Auth Review, P2P Prep, Appeal Prep).
Decision Tree
A structured visualization in the Clinical Review pane showing each clinical criterion as a question with an answer (Yes/No/Pending), supporting evidence, and source references.
Document Intelligence
Lilee's core AI pipeline that handles intake, OCR extraction, classification, field extraction, tagging, summary generation, and clinical review of healthcare documents.
Stats Bar
The summary bar at the top of the Intake Dashboard showing total documents, in-review count, completed count, and urgent item count.
Detail Pane
A panel on the right side of the Intake Dashboard that shows context-specific information about the selected document (Detected Workflow, Clinical Review, Authorization Review, History, Notes, Nurse Letter, or Document Viewer).
Form Type
A document type that your organization has enabled for processing in the Config page. Each form type has associated base fields and optional custom fields.
Custom Field
An organization-defined extraction field added to a form type in the Config page. Custom fields extend the AI extraction beyond built-in fields.
Organization Type
Whether your Lilee instance is configured as a Payer organization or Provider organization. Determines available features, document types, and interface labels.
High Dollar List (HDL)
A feature for payer organizations that tracks high-value patient accounts. Imported from spreadsheets and linked to incoming documents via automatic notifications.
Healthcare Terms
Prior Authorization (Prior Auth)
The process of obtaining approval from a health plan before a medical service is rendered. Providers submit prior authorization requests to demonstrate medical necessity.
Utilization Management (UM)
The process health plans use to ensure that medical services are clinically appropriate, medically necessary, and delivered in the right care setting. Includes prior authorization, concurrent review, and retrospective review.
Care Management (CM)
The coordination of care for members with complex, chronic, or high-risk conditions. Includes assessment, care planning, outreach, and follow-up.
Medical Necessity
The determination that a healthcare service is clinically appropriate and required based on evidence-based criteria. A key standard in prior authorization decisions.
Clinical Criteria
Evidence-based guidelines used to evaluate medical necessity. In Lilee, this refers to Medicare NCD, LCD, and Article policies. Commercial criteria sets include InterQual and MCG.
Adverse Determination
A denial or modification of a requested service. The formal term for when a prior authorization request is not approved as submitted.
Concurrent Review
A review of an ongoing treatment or inpatient stay to evaluate whether continued care is medically necessary. Used for extension requests and continued stay authorizations.
Retrospective Review (Retro Auth)
Authorization sought after a service has already been provided. Evaluated based on whether the service was medically necessary at the time it was delivered.
Peer-to-Peer (P2P)
A clinical discussion between the health plan's Medical Director and the requesting provider. Typically occurs when a prior authorization request does not meet criteria at the nurse reviewer level.
Turnaround Time (TAT)
The elapsed time from receipt of a request to issuance of a determination. In Lilee, urgent requests have a 72-hour TAT and standard requests have a 7-day TAT.
Payer
An organization that provides health insurance coverage -- typically a health plan, insurance company, or managed care organization. In Lilee, payer organizations process incoming authorization requests.
Provider
A physician, hospital, clinic, or other healthcare professional or facility that delivers medical services. In Lilee, provider organizations receive and respond to payer communications.
Member
An individual enrolled in a health plan. In patient-facing contexts, "patient" may also be used. Lilee uses "patient" in its interface for clarity.
Durable Medical Equipment (DME)
Medical equipment designed for repeated use, such as wheelchairs, oxygen equipment, CPAP machines, hospital beds, and walkers. DME authorizations have specific LCD criteria.
Appeal
A formal request to reconsider an adverse determination (denial). Members and providers can submit appeals with additional clinical information to support their case.
Grievance
A complaint from a member about the quality of care, access to services, or the health plan's operations. Different from an appeal, which contests a specific coverage decision.
Referral
A recommendation for a patient to receive care from a specialist or other provider. Some health plans require prior authorization for referrals.
Clinical Coding Terms
CPT Code
Current Procedural Terminology code. A five-digit numeric code that identifies medical procedures and services. Maintained by the American Medical Association. Example: 97110 (Therapeutic Exercises).
HCPCS Code
Healthcare Common Procedure Coding System code. Used for services, equipment, and supplies not covered by CPT codes, particularly DME and injectable drugs. Includes Level I (CPT) and Level II (alphanumeric) codes. Example: E1390 (Oxygen concentrator).
ICD-10 Code
International Classification of Diseases, 10th Revision code. Used for diagnosis coding. Example: E11.9 (Type 2 Diabetes Mellitus without complications).
Revenue Code
A four-digit code used on institutional claims to identify specific services or accommodations. Common in inpatient billing. Example: 0420 (Physical Therapy - General).
NPI
National Provider Identifier. A unique 10-digit number assigned to healthcare providers in the United States. Used to identify providers in transactions and records.
Coverage Policy Terms
National Coverage Determination (NCD)
A Medicare coverage policy established at the national level by CMS. NCDs apply uniformly across the country and take precedence over local policies. Example: NCD 220.6 (Positron Emission Tomography).
Local Coverage Determination (LCD)
A Medicare coverage policy established by a Medicare Administrative Contractor (MAC) for its specific jurisdiction. LCDs provide regional coverage guidance when no NCD exists.
Article
Supplementary guidance documents published by MACs that provide billing and coding instructions related to LCDs. Articles contain practical implementation details.
Medicare Administrative Contractor (MAC)
A regional organization contracted by CMS to process Medicare claims and establish local coverage policies. Different MACs cover different geographic areas.
CMS
Centers for Medicare & Medicaid Services. The federal agency that administers Medicare, Medicaid, and other health programs. CMS establishes NCDs and oversees MACs.
Compliance and Security Terms
HIPAA
Health Insurance Portability and Accountability Act. Federal law that establishes standards for protecting sensitive patient health information.
PHI
Protected Health Information. Individually identifiable health data protected under HIPAA. Includes patient names, dates of birth, member IDs, diagnoses, and treatment information.
Audit Trail
A chronological record of all user actions in the system. Lilee logs every action including document views, edits, clinical review decisions, authorization submissions, and configuration changes.
Row Level Security (RLS)
A database security mechanism that restricts data access based on the user's organization. Ensures that each organization can only see its own data.
RBAC
Role-Based Access Control. A security approach where permissions are assigned to roles, and users are assigned to roles. Determines what each user can see and do in the platform.
BAA
Business Associate Agreement. A HIPAA-required contract between a covered entity and a business associate that handles PHI on its behalf.
NCQA
National Committee for Quality Assurance. An accreditation body for health plans that sets standards for UM, CM, and quality programs.
SLA
Service Level Agreement. Contractual time requirements for processing authorizations and other workflows.
Integration Terms
EHR
Electronic Health Record. A digital system for storing and managing patient health information. Lilee integrates with EHR systems for member lookup, provider validation, and authorization submission.
AcuityNXT
The EHR system currently integrated with Lilee for authorization management, member lookup, and provider search.
OCR
Optical Character Recognition. Technology that extracts text from scanned documents and images. Lilee uses Reducto AI for OCR processing.
Reducto
The third-party AI service Lilee uses for document parsing, splitting, and data extraction from PDFs and images.
Mastra
The AI agent framework that powers Ellie and Lilee's document processing workflows. Mastra manages AI tool usage, conversation handling, and workflow orchestration.
Terms are updated as new features and integrations are added to the platform. If you encounter a term not listed here, contact [email protected].
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