Healthcare-Glossary

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

A

Accountable Health Plan (AHP) - AHPs can be IDSs, MCOs, Health Networks, partnerships or joint ventures between practitioners, providers or payers that would assume responsibility for delivering medical care and managing the funds required to pay for the services rendered. Physicians and other providers would work for, contract with or own these health plans. When an IDS or hospital group or IPA operates one or more health insurance benefit products, or a managed care organization acquires a large scale medical delivery component, it qualifies as an Accountable Health System or Accountable Health Plan.

Accountable Health Partnership - An organization of doctors and hospitals that provides care for people organized into large groups of purchasers.

Accrual - The amount of money that is set aside to cover expenses. The accrual is the plan's best estimate of what those expenses are, and (for medical expenses) is based on a combination of data from the authorization system, the claims system, lag studies, and the plan's prior history.

Actively-at-Work - Describes insurer's policy requirement indicating that coverage will not go into effect until the employee's first day of work on or after the effective date of coverage. May also apply to dependents disabled on the effective date.

Accreditation - The process by which an organization recognizes a provider, a program of study or an institution as meeting predetermined standards. Two organizations that accredit managed care plans are the National Committee for Quality Assurance (NCQA) and the Joint Commission on Accreditation of Health Care Organizations (JCAHO). JCAHO also accredits hospitals and clinics. CARF accredits rehabilitation providers

Activities of Daily Living (ADL's, ADL) - An individual's daily habits such as bathing, dressing and eating. ADLs are often used as an assessment tool to determine an individual's ability to function at home, or in a less restricted environment of care.

Activity-Based Costing (ABC) - Activity-based costing defines healthcare costs in terms of a healthcare organization's processes or activities. The costs are then associated with significant activities or events. It relies on the following 3 step process: 1) Activity mapping, which involves mapping activities in an illustrated sequence; 2) Activity analysis, which involves defining and assigning a time value to activities; and, 3) bill of activities, which involves generating a cost for each main activity.

Actuary - In insurance, a person trained in statistics, accounting and mathematics who determines policy rates, reserves, and dividends by deciding what assumptions should be made with respect to each of the risk factors involved (such as the frequency of occurrence of the peril, the average benefit that will be payable, the rate of investment earnings, if any, expenses, and persistency rates), and who endeavors to secure as valid statistics as possible on which to base his assumptions. Professionally trained individual, usually with experience or education in insurance, who conducts statistical studies such as determining insurance policy rates, dividend reserves and dividends, as well as conducts various other statistical studies. A capitated health provider would not accept or contract for capitated rates, or agree to a capitated contract without an actuarial determining the reasonableness of the rates.

Acute Care - A pattern of health care in which a patient is treated for an acute (immediate and severe) episode of illness, for the subsequent treatment of injuries related to an accident or other trauma, or during recovery from surgery. Specialized personnel using complex and sophisticated technical equipment and materials usually give acute care in a hospital. Unlike chronic care, acute care is often necessary for only a short time.
Adjudication Claims adjudication in health insurance refers to the determination of a member's payment, or financial responsibility, after a medical claim is applied to the member's insurance benefits.
- Processing claims according to contract.

Adjusted Admissions - Adjusted admissions are equivalent to the sum of inpatient admissions and an estimate of the volume of outpatient services. This is a measure of all patient care activity undertaken in a hospital, both inpatient and outpatient. This estimate is calculated by multiplying outpatient visits by the ratio of outpatient charges per visit to inpatient charges per admission.

Adjusted Community Rate -(ACR) - Health plans and insurance companies estimate their ACRs annually and adjust subsequent year supplemental benefits or premiums to return any excess Medicare revenue above the ACR to enrollees. This are the estimated payment rates that health plans with Medicare risk contracts would have received for their Medicare enrollees if paid their private market premiums, adjusted for differences in benefit packages and service use.

Adjusted Drug Benefit List - A small number of medications often prescribed to long-term patient. It is also called a drug maintenance list. A health plan, CMS or 3rd party administrator can modify it from time to time.

Adjusted Community Rating - (ACR) - ACR is a rating by community influenced by certain group demographics. Estimated payment rates that health plans with Medicare risk contracts would have received for their Medicare enrollees if paid their private market premiums, adjusted for differences in benefit packages and service use. Health plans estimate their ACRs annually and adjust subsequent year supplemental benefits or premiums to return any excess Medicare revenue above the ACR to enrollees. See Adjusted Average Per Capita Cost, Medicare Risk Contract. See also Community Rating.

Adjusted Per Capita Cost (APCC) - Medicare benefits estimation for a person in a given county using sex, age, institutional status, Medicaid disability, and end stage renal disease status as a basis.

Adjusted Payment Rate (APR) - The Medicare capitated payment to risk-contract HMOs. For a given health plan, the APR is determined by adjusting county-level AAPCCs to reflect the relative risks of the plan's enrollees.

Affiliated Provider - A health care provider or facility that is part of the HMO's network usually having formal arrangements to provide services to the HMO member.

Administrative Services Organization - (ASO) - A contract between an insurance company and a self-funded plan where the insurance company performs administrative services only and the self-funded entity assumes all risk.

Administrative Code Sets - Code sets that characterize a general business situation, rather than a medical condition or service. Under HIPAA, these are sometimes referred to as non-clinical or non-medical code sets. Compare to medical code sets.

Administrative Costs - Costs related to utilization review, insurance marketing, medical underwriting, agents' commissions, premium collection, claims processing, insurer profit, quality assurance programs, and risk management. Administrative costs also refer to certain allowable costs on hospital CMS cost reports, usually considered overhead. Rules exist which disallow certain expenses, such as marketing. Costs not linked directly to the provision of medical care. Includes marketing, claims processing, billing, and medical record keeping, among others.

Affiliation - An agreement between two or more otherwise independent entities or individuals that defines how they will relate to one another. Agreements between hospitals may specify procedures for referring or transferring patients. Agreements between providers may include joint managed care contracting.

Aid to Families with Dependent Children (AFDC) - The federal AFDC program provides cash welfare to: (1) needy children who have been deprived of parental support and (2) certain others in the household of such child. States administer the AFDC program with funding from both the federal government and state. The Personal Responsibility & Work Responsibility Act of 1996, enacted in August 1996, replaced AFDC with a new program called Temporary Assistance for Needy Families (TANF).

Ambulatory Care - Due to advances in technology, health care professionals now perform more and more procedures safely on an outpatient basis. This new capability saves both time and money, as patients do not have the expense of spending additional time in the hospital. Ambulatory care refers to a wide range of medical services and procedures that are conducted on an outpatient basis. Ambulatory care can be given at a hospital, doctor’s office, or ambulatory surgery center (ASC). Procedures conducted at these facilities include blood tests, X-rays, endoscopy, some biopsies, catheterizations, minor surgery, childbirth, plastic surgery, eye care and much more Ambulatory Care - Health services provided without the patient being admitted. Ambulatory care is also called outpatient care. The services of ambulatory care centers, hospital outpatient departments, physicians' offices and home health care services fall under this heading provided that the patient remains at the facility less than 24 hours. No overnight stay in a hospital is required.

Ambulatory Care Facility - A medical care center that provides a wide range of healthcare services: that include preventive care, acute care, surgery and outpatient care in a centralized facility.

Ambulatory Surgery - Surgical procedures performed that do not require an overnight hospital stay. Procedures can be performed in a hospital or a licensed surgical center. Ambulatory Surgery is also called Outpatient Surgery.

Anonymous Data – under HIPAA, this refers to data that were collected without identifiers and that were never linked to an individual. Coded data are not anonymous.

Assignment of Benefits - An arrangement by which a patient requests that their health benefit payments be made directly to a designated person or facility, such as a physician or hospital.

Authorization – Any document designating any permission. In health care, authorization may refer to "authorization to disclose" private information, "authorization to treat" or "authorization to pay", as in "pre-authorization" required by many insurance companies and health plans. In the case of pre-authorization, the managed care organization may require approval prior to the receipt of care. (Generally, this is different from a referral in that, an authorization can be a verbal or written approval from the MCO whereas a referral is generally a written document that must be received by a doctor before giving care to the beneficiary.) The HIPAA Privacy Rule requires authorization or waiver of authorization for the use or disclosure of identifiable health information for research (among other activities). The authorization must indicate if the health information used or disclosed is existing information and/or new information that will be created. The authorization form may be combined with the informed consent form, so that a patient need sign only one form. An authorization must include the following specific elements: a description of what information will be used and disclosed and for what purposes; a description of any information that will not be disclosed, if applicable; a list of who will disclose the information and to whom it will be disclosed; an expiration date for the disclosure; a statement that the authorization can be revoked; a statement that disclosed information may be re-disclosed and no longer protected; a statement that if the individual does not provide an authorization, s/he may not be able to receive the intended treatment; the subject's signature and date. See also HIPAA, Privacy and Pre-authorization.

Age/Sex Factor - Underwriting measurement representing the medical risk costs of one population compared to another based on age and sex factors.

Age/Sex rates - (ASR) - Also called table rates, they are given group products' set of rates where each grouping, by age and sex, has its own rates. Rates are used to calculate premiums for group billing and demographic changes are adjusted automatically in the group.

Age-at-Issuance Rating - A method for establishing health insurance premiums whereby an insurer's premium is based on the age of individuals when they first purchased health insurance coverage. This is an older form of actuarial assessment.

Age-Attained Rating - Similar to the above, this method for establishing health insurance premiums whereby an insurer's premium is based on the current age of the beneficiary. Age-attained-rated premiums increase in price, as the purchasers grow older.

Agency for Health Care Policy and Research - (AHCPR) - The agency of the Public Health Service responsible for enhancing the quality, appropriateness and effectiveness of health care services.

B

Balance Billing - The practice of billing a patient for the fee amount remaining after insurer payment and co-payment have been made. Under Medicare, the excess amount cannot be more than 15 percent above the approved charge.

Base Capitation - Specified amount per person per month to cover healthcare cost, usually excluding pharmacy and administrative costs as well as optional coverages such as mental health/substance abuse services.

Base Year Costs - In Medicare, the amount a hospital actually spent to render care in a previous time period. Depending on the hospital's Medicare cost reporting period, the base year was the fiscal year ending on or after September 30, 1982 and before September 30, 1983 for hospitals in operation at that time. Recent legislation has made dramatic changes in cost reporting opportunities for healthcare providers, limiting these reimbursements.

Bed Days - Number of inpatient hospital days per 1,000 health plan members for a specified period, usually annual.

Behavioral Health, Behavioral Healthcare - An umbrella term that includes mental health, psychiatric, marriage and family counseling, addictions treatment and substance abuse. Services are provided by a myriad of providers, including social workers, counselors, psychiatrist, psychologists, neurologists and even family practice physicians. Many states have "parity" laws that attempt to require that behavioral health insurance coverage be provided "on par" to physical health coverage.

Benefit Package - Aggregate services specifically defined by an insurance policy or HMO that can be provided to patients. The services a payer offers to a group or individual. The package will specify include cost, limitation on the amounts of services, and annual or lifetime spending limits.

Benefits - Benefits are specific areas of Plan coverage's, i.e., outpatient visits, hospitalization and so forth, that make up the range of medical services that a payer markets to its subscribers. Also, a contractual agreement, specified in an Evidence of Coverage, determining covered services provided by insurers to members.

Billed Claims - Fees submitted by a health care provider for services rendered to a covered person. Fees billed and fees paid are rarely synonymous.

Biometric Identifier - Identifying information based on a physical characteristic (e.g., a fingerprint). Confidentiality laws and HIPAA privacy rules refer to biometric identifiers.

Business Associate – Under HIPAA rules, this term refers to an outside person/entity that performs a service on behalf of the health care provider (including a researcher) or the health care institution during which individually identifiable health information is created, used, or disclosed. For example, web hosting or data storage companies will be business associates if they receive protected health information. In addition, third parties that handle billing for a research study, or recruitment and screening, will also be business associates. Certain exceptions apply.

 C

Cafeteria Plan - Arrangements under which employees may choose their own benefit structure. Sometimes these are varying benefit plans or add-ons provided through the same insurer or 3rd party administrator, other times this refers to the offering of different plans or HMOs provided by different managed care or insurance companies.

 Capitation - Specified amount paid periodically to health provider for a group of specified health services, regardless of quantity rendered. Amounts are determined by assessing a payment "per covered life" or per member.
The method of payment in which the provider is paid a fixed amount for each person served no matter what the actual number or nature of services delivered.
The cost of providing an individual with a specific set of services over a set period of time, usually a month or a year. Providers are not reimbursed for services that exceed the allotted amount. The rate may be fixed for all members or it can be adjusted for the age and gender of the member, based on actuarial projections of medical utilization.

Carrier - An insurer; an underwriter of risk that finances health care. Also refers to any organization, which underwrites or administers life, health or other insurance programs. When an employer has a “self-insured” plan, the carrier (such as Aetna or Blue Cross) may not serve as carrier in this case, but may serve only as “third party administrator”.

Case Management - The monitoring and coordination of treatment rendered to patients with specific diagnosis or requiring high-cost or extensive services. Method designed to accommodate the specific health services needed by an individual through a coordinated effort to achieve the desired health outcome in a cost effective manner. The monitoring and coordination of treatment rendered to patients with specific diagnosis or requiring high-cost or extensive services. It is a process by which all health-related matters of a case are managed by a physician or nurse or designated health professional. Physician case managers coordinate designated components of health care, such as appropriate referral to consultants, specialists, hospitals, ancillary providers and services. Case management is intended to ensure continuity of services and accessibility to overcome rigidity, fragmented services, and the miss-utilization of facilities and resources. It also attempts to match the appropriate intensity of services with the patient's needs over time. Case Management - A program that assists the patient in determining the most-appropriate and cost effective treatment plan including coordinating and monitoring the care with the ultimate goal of achieving the optimum healthcare outcome.

Case Mix - The mix of patients treated within a particular institutional setting, such as the hospital. Patient classification systems like DRGs can be used to measure hospital case mix. (See also DRGs and Case-Mix Index). Measurement reflecting servicing needs, uses of hospital capabilities, and the general rate of hospital admissions. The types of inpatients a hospital or post acute facility treats. The more complex the patients' needs, the greater the amount spent for patient care. Case mix is generally established by estimating the relative frequency of various types of patients seen by the provider in question during a given time period and may be measured by factors such as diagnosis, severity of illness, utilization of services, and provider characteristics.

Case Manager - A nurse, doctor, or social worker who works with patients, providers and insurers to coordinate all services deemed necessary to provide the patient with a plan of medically necessary and appropriate health care.

Carve-in - A generic term that refers to any of a continuum of joint efforts between clinicians and service providers; also used specifically to refer to health care delivery and financing arrangements in which all covered benefits (e.g., behavioral and general health care) are administered and funded by an integrated system.

Carve Out - Practice of excluding specific services from a managed care organization's capitated rate. In some instances, the same provider will still provide the service, but they will be reimbursed on a fee-for-service basis. In other instances, carved out services will be provided by an entirely different provider. A payer strategy in which a payer separates ("carves-out") a portion of the benefit and hires an MCO to provide these benefits. A health care delivery and financing arrangement in which certain specific health care services that are covered benefits (e.g., behavioral health care) are administered and funded separately from general health care services. The carve-out is typically done through separate contracting or sub-contracting for services to the special population. Common carve outs include such services as psychiatric, rehab, chemical dependency and ambulatory services. Increasingly, oncology and cardiac services are being carved out. This permits the payer to create a separate health benefits package and assume greater control of their costs. Many HMOs and insurance companies adopt this strategy because they do not have in-house expertise related to the service "carved out." A "carve-out" is typically a service provided within a standard benefit package but delivered exclusively by a designated provider or group. This process may or may not seem transparent to the subscriber, but it often means that separate UR and pre-certification entities are involved as well as different payers and providers. Carve-outs are also called sub-contractors, sub-captivators or junior capitation contracts.

Catastrophic Coverage for Drugs - A specific term used in the Medicare Part D plans that refers to the event of a beneficiary's total drug costs reaching a certain maximum (in 2006 that maximum was $5451.25, for example), after which the beneficiary pays a small coinsurance (like 5%) or a small co-payment for covered drug costs until the end of that calendar year.

Catastrophic Health Insurance - Policy that provides protection primarily against the higher costs of treating severe or lengthy illnesses or disabilities. Generally such policies cover all, or a specified percentage of, medical expenses above an amount that is the responsibility of another insurance policy up to a maximum limit of liability. These are "add on" benefits that begin coverage once the primary insurance policy reaches its maximum.

Certificate of Authority (COA) - Issued by state governments, it gives a health maintenance organization or insurance company its license to operate within the state.

Certificate of Coverage (COC) - Outlines the terms of coverage and benefits available in a carrier's health plan.

Certificate of Need (CON) - In some states, a state agency must review and approve certain proposed capital expenditures, changes in health services provided, and purchases of expensive medical equipment. Before the request goes to the state, a local review panel (the health systems agency or HSA) must evaluate the proposal and make a recommendation. CON is intended to control expansion of facilities and services by preventing excessive or duplicative development of facilities and services. Many states have sunsetted or eliminated their CON processes and requirements.

Centers for Medicare and Medicaid Services (CMS) - The Centers for Medicare & Medicaid Services (CMS) is a Federal agency within the U.S. Department of Health and Human Services. Programs for which CMS is responsible include Medicare, Medicaid, State Children's Health Insurance Program (SCHIP), HIPAA and CLIA. Formerly was HCFA. Centers for Medicare & Medicaid Services has historically maintained the UB-92 institutional EMC format specifications, the professional EMC NSF specifications, and specifications for various certifications and authorizations used by the Medicare and Medicaid programs. CMS is responsible for oversight of HIPAA administrative simplification transaction and code sets, health identifiers, and security standards. CMS also maintains the HCPCS medical code set and the Medicare Remittance Advice Remark Codes administrative code set.

Certificate of Creditable Coverage - A written certificate issued by a group health plan or health insurance issuer (including an HMO) that states the period of time that the beneficiary was covered by that health plan. These certificates are often required by plans prior to waiving or reducing the preexisting clauses in new coverages. Also see Pre-Existing.

Certified Health Plan - A managed health care plan, certified by the Health Services Commission and the Office of the Insurance Commissioner to provide coverage for the Uniform Benefits Package to state residents. Regulations vary by state since some states require only HMOs to certify but not PPOs, IPAs or MSOs. Increasingly these regs are becoming more consistent state by state.

Claim Scrubbing - It is a method designed to detect claim coding and compliance issues before submission for reimbursement. Identifying claim errors efficiently can dramatically accelerate practice's reimbursement cycle and detect system inefficiencies.

Coinsurance - Coinsurance is the portion of medical costs that are shared by both the Insured (the patient) and the Insurer. For example, if you have an 80% to $5,000 coinsurance; The Insurer is responsible for 80% of the next $5,000 in covered medical expenses. The Insured is responsible for 20% of that same $5,000 in covered medical expenses. So in the above mentioned policy with $1,000 deductible and 80% co-insurance to $5,000; If a covered event occurred that had a total cost of $10,000, the insured would be responsible for the first $1,000 (deductible) Of the next $5,000 in covered expenses, the insured would pay another $1,000 (coinsurance).
After deductibles and coinsurance are satisfied, Insurance Companies pay 100% of all other covered expenses. So for this example the Insured would pay $2,000 and the Insurer would pay $8,000.

Computerized Medical Record (CMR) - Makes the documents of level 1 electronically available.

Co-payment(or co-pay) - The fixed dollar amount that your policy requires you to pay as your share of the cost of certain services each time you receive care.

 Consultation - Services rendered by a physician whose opinion or advice is requested by another physician for further evaluation or management of the patient.

 Covered Services - The services for which the “Plan” provides benefits under the terms of your contract.

 CPOE - In an effort to cut down on the increasing number of patient injuries and deaths, the healthcare industry has been pressured to introduce Computerized Physician Order Entry (CPOE) systems. While CPOEs were originally heralded as a cornerstone of improved patient safety (no more illegible prescriptions sent to hospital pharmacies), there are many studies (including a recent report in the Journal of the American Medical Association) which show that use of CPOEs might actually increase medical prescription errors

CPT - Current Procedural Terminology Physicians' Current Procedural Terminology (CPT®), Fourth Edition, is a listing of descriptive terms and identifying codes for reporting medical services and procedures. The purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliable nationwide communication among physicians, patients, and third parties. CPT descriptive terms and identifying codes currently serve a wide variety of important functions. This system of terminology is the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs. CPT is also used for administrative management purposes such as claims processing and developing guidelines for medical care review. The uniform language is likewise applicable to medical education and research by providing a useful basis for local, regional, and national utilization comparisons.
The CPT Editorial Panel is responsible for maintaining the CPT nomenclature. This panel is authorized to revise, update, or modify the CPT codes.

 Custodial Care - Maintenance care of a patient which is designed to assist the patient in daily living and not primarily provided for the treatment of an illness, disease or condition. Custodial care includes but is not limited to help in walking, bathing and feeding.

Customary Charges - The fees most providers charge for a certain procedure. These charges are determined based on charge data collected from providers in a geographical area at a certain time period.

Customization - Pricing for EMR systems is highly dependent on each practice's unique needs. Because every medical practice has distinct requirements, systems usually need to be custom tailored. This is due to the majority of EMR systems being based on templates that are initially general in scope. In many cases, these templates can then be customized in co-operation with the vendor/developer to better fit a medical specialty, environment or other specified needs. There are also EMR systems available that do not use templates and therefore can be easily personalized by each individual user, for example those based on Concept Processing technology.

D

Date of Service - The date on which a service was rendered.

Deductible - Dollar amount that an insured person or family must pay each year before an insurer will assume any liability for the remaining cost of covered services. This is done so that people will make sure that any problem that an insured might have really needs medical assistance. It is a way for Insurance Companies to keep premium costs down.

Denial of Benefits - A rejection of an entire claim or part of a claim.

Dependent - Person (spouse or child) other than the subscriber who is covered in the subscriber's benefit certificate. The Dependent may also be a "Member" or "Beneficiary".

Diagnostic Service - A test or procedure rendered because of specific symptoms which is directed toward the determination of the definite condition or disease.

Diagnostic Tests - Tests and procedures ordered by a physician to determine if the patient has a certain condition or disease based upon specific signs or symptoms demonstrated by the patient. Such diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory, or pathology services.

Discharge Date - Date the patient left the hospital.

 E

Electronic Health Record (EHR) - An electronic repository of information regarding the health of an individual. It is also a generic term for all electronic patient care systems.   EHR’s imply a level of interoperability beyond the capability of an EMR (Electronic Medical Record).
Read more….

Electronic Medical Record (EMR) - Electronic Medical record has a level of sophistication beyond a document management system. An EMR is a provider-based medical record that includes all health documentation for one person covering all services provided within an enterprise.
Read more….

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) - A Medicaid program for recipients younger than 21 that provides screening, vision, hearing, and dental services at intervals that meet recognized standards of medical and dental practices and at other intervals as necessary to determine the existence of physical or mental illnesses or conditions.

 EDI Translator - Used in electronic claims and medical record transmissions, this is a software tool for accepting an EDI transmission and converting the data into another format, or for converting a non-EDI data file into an EDI format for transmission. See also Electronic Data Interchange.

Effective Date - The date on which the coverage of a plan goes into effect at 12:01 a.m.

Elective Surgery - Surgery for a condition that is not considered an emergency.

Electronic Claim Processing - This is the processing medical claim electronically which had many benefits like, receives priority processing, Electronic medical claims submitted go directly to the payer's processing unit, ensuring faster turnaround. Paper claims are processed only after manual sorting and batching. Many practices are turning to electronic claims processing because of the vast time and money savings that result. Processing insurance claims electronically improves cash flow, reduces the expense of claims processing and streamlines internal processes allowing a practice to focus on patient care.
The reduction in insurance reimbursement time results in a significant increase in cash available for the needs of a growing practice. In addition, by reducing the internal expenses associated with processing paper claims, reduced labor, office supplies and postage all contribute to the bottom of the practice when submitting claims electronically.

Electronic Data Interchange (EDI) - The automated exchange of data and documents in a standardized format. In health care, some common uses of this technology include claims submission and payment, eligibility, and referral authorization. It refers to the exchange of routine business transactions from one computer to another in a standard format, using standard communications protocols.

Electronic Media Claims - A flat file format used to transmit or transport claims, such as the 192-byte UB-92 Institutional EMC format and the 320-byte Professional EMC NSF.

Electronic Medical Record (EMR) – is a computer-based record containing health care information. This technology, when fully developed, meets provider needs for real-time data access and evaluation in medical care. Together with clinical workstations and clinical data repository technologies, the EMR provides the mechanism for longitudinal data storage and access. A motivation for healthcare entities to implement this technology derives from the need for medical outcome studies, more efficient care, speedier communication among providers and management of health plans. This record may contain some, but not necessarily all, of the information that is in an individual's paper-based medical record. One goal of HIPAA is to protect identifiable health information as the system moves from a paper-based to an electronic medical record system. See also Computerized Medical Record.

Electronic Remittance Advice - Any of several electronic formats for explaining the payments of health care claims.

Eligibility - A determination of whether or not a person meets the requirements to participate in the plan.

Eligibility Period - The period of time a group stipulates must elapse before a group member becomes eligible for benefits.

Electronic Patient Record (EPR) - Is a patient-centered record with information from multiple institutions.

Electronic Health Record (EHR) - Adds general health-related information to the EPR that is not necessarily related to a disease.

Electronic Claims Record (ECR) - Adds health insurance claims information to the EMR.

Emergency - An emergency is a medical or behavioral condition of which the onset is sudden. It manifests itself by symptoms of such severity that a prudent lay person with an average knowledge of medicine and health could reasonably expect that the absence of immediate medical attention would result in: placing the health of the afflicted person in serious jeopardy; placing the health of an individual with a behavioral health condition or others in serious jeopardy; causing serious impairment of the individual's bodily functions; causing serious dysfunction of any bodily organ or part; causing serious disfigurement of the afflicted individual.

Emergency Care - Care for patients with severe or life-threatening conditions that require immediate intervention.

Emergency Center, Emergi-center - Non-hospital affiliated health facility that provides short-term care for minor medical emergencies or procedures needing immediate treatment; also called urgi-center, urgent center or free standing emergency medical service center.

Encounter - A contact between an individual and the health care system for a health care service or set of services related to one or more medical conditions.

 Encounter Data - Detailed data about individual services provided by a capitated managed care entity. The level of detail about each service reported is similar to that of a standard claim form. Encounter data are also sometimes referred to as "shadow claims".

Encounter Report - A report that supplies management information about services provided each time a patient visits a provider.

Exclusion - Specific conditions or circumstances that are not covered under the benefit agreement. It is very important to consult the benefit contract to understand what services are not covered benefits.

Exclusive Provider Arrangement (EPA) - An indemnity or service plan that provides benefits only if care is rendered by the institutional and professional providers with which it contracts (with some exceptions for emergency and out-of-area services).

Exclusive Provider Organization (EPO) - A healthcare benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but which does not cover out-of-network care.

Expiration Date - The date indicated in a contract as the date coverage expires at 12:00 midnight.

Explanation of Benefits (EOB) - A form sent to the enrollee after a claim for payment has been processed by the health plan. The form explains the action taken on that claim. This explanation usually includes the amount paid, the benefits available, reasons for denying payment, or the claims appeal process.

Extended Care Facility - An institution devoted to providing medical, nursing or custodial care for an individual over a prolonged period of time as during the course of a chronic disease or during the rehabilitation phase after an acute illness.

F

Facility - A facility is a hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility.

Family Deductible - The dollar amount of the member's health benefit coverage that must be met each calendar year before payment can be made on claims. There is a maximum out-of-pocket amount that will satisfy the family deductible. Once that deductible is reached, all claims are then paid at 100% of allowable charges.

Federally Qualified HMO – is a prepaid health plan that has met strict federal standards and has been granted qualification status. A federally qualified HMO is eligible for loans and loan guarantees not available to non-qualified plans. Employers of 25 or more workers were, until recently, required to offer a federally qualified HMO if the plan requested to be included in the company's health benefits program.

 Fee Disclosure – Situation where the Physicians and caregivers discuss their charges with patients prior to treatment.

Fee-For-Service (FFS) - Traditional method of payment for health care services where specific payment is made for specific services rendered. Usually people speak of this in contrast to capitation, DRG or per diem discounted rates, none of which are similar to the traditional fee for service method of reimbursement. Under a fee-for-service payment system, expenditures increase if the fees themselves increase, if more units of service are provided, or if more expensive services are substituted for less expensive ones. This system contrasts with salary, per capita, or other prepayment systems, where the payment to the physician is not changed with the number of services actually used. Payment may be made by an insurance company, the patient or a government program such as Medicare or Medicaid. With respect to the physicians or other supplier of service, this refers to payment in specific amounts for specific services rendered--as opposed to retainer, salary, or other contract arrangements. In relation to the patient, it refers to payment in specific amounts for specific services received, in contrast to the advance payment of an insurance premium or membership fee for coverage, through which the services or payment to the supplier are provided.

Fee Schedule - A listing of accepted fees or established allowances for specified medical procedures. As used in medical care plans, it usually represents the maximum amounts the program will pay for the specified procedures. The fee determined by an MCO to be acceptable for a procedure or service, which the physician agrees to accept as payment in full. Also known as a fee allowance, fee maximum, or capped fee.

 First Dollar coverage - Insurance coverage with no front-end deductible where coverage begins with the first dollar of expense incurred by the insured for any covered benefit.

Formatting and Protocol Standards - Data exchange standards which are needed between CPR systems, as well as CPT and other provider systems, to ensure uniformity in methods for data collection, data storage and data presentation. Proactive providers are current in their knowledge of these standards and work to ensure their information systems conform to the standards.

Formulary - An approved list of prescription drugs; a list of selected pharmaceuticals and their appropriate dosages felt to be the most useful and cost effective for patient care. Organizations often develop a formulary under the aegis of a pharmacy and therapeutics committee. When used by hospitals or clinics, a formulary is intended as a recommendation usually and not considered a requirement. However, when used In HMOs or Prescription Drug Plans, such as Medicare Part D Plans, physicians are often required to prescribe from the formulary. If a physician prescribes a drug not on the formulary, the patient may not be able to experience any discount or reimbursement for the expense. Formularies are supposed to be based on evaluations of efficacy, safety, and cost-effectiveness of drugs, but increasingly formularies are based on cost and expense factors. Patients pay varying co-pays for drugs that are on formulary. For drugs that are not on formulary, patients must pay the entire cost of the drug. Formularies vary between drug plans and differ in the breadth of drugs covered and costs of co-pay and premiums. Most formularies cover at least one drug in each drug class, and encourage generic substitution. It is a list of drugs covered by a plan and is also known as “preferred drug list”.

 G

Gatekeeper - A primary care physician, utilization review, case management, local agency or managed care entity responsible for determining when and what services a patient can access and receive reimbursement for. In HMOs, it is commonly an arrangement, in which a primary care provider serves as the patient's agent, arranges for and coordinates appropriate medical care and other necessary and appropriate referrals. In that case, the gatekeeper PCP is involved in overseeing and coordinating all aspects of a patient's medical care. In order for a patient to receive a specialty care referral or hospital admission, the PCP must preauthorize the visit, unless there is an emergency. The term gatekeeper is also used in health care business to describe anyone (EAP, employer based case manager, UR entity, case manager, etc.) that makes the decision of where a patient will receive services.

Generic Drug or Generic Equivalent - A drug which is exactly the same as a brand name drug and which may be manufactured and marketed after the brand name drug’s patent expires (approximately 9-10 years after the brand-name drug entered the market). Generic drugs cost significantly less than brand name drugs, and are identical in terms of efficacy, safety, side effect profile, and dosing. Important exceptions to this may include drugs such as a immunosuppressant or drugs with a “narrow therapeutic index” such as an anti-arrhythmic. “Narrow therapeutic index” refers to drugs that have a high rate of side effects at commonly administered dosages. Also see Formulation Substitution.

Group Health Plan - A health plan that provides health coverage to employees, former employees, and their families, and is supported by an employer, employee organization or other organized group.

Group Health Plan Number - A number that is assigned to all group health plans in the future by the CMS division administering the transactions, code sets, security and administrative simplification portions of the Health Insurance Portability and Accountability Act (HIPAA) GSA - General Services Administration. See also HIPAA and CMS .

Group Insurance - Any insurance policy or health services contract by which groups of employees (and often their dependents) are covered under a single policy or contract, issued by their employer or other group entity.

Group Model HMO, Group Network HMO, Group Practice Model HMO - An HMO that contracts with one or more independent group practice to provide services to its members in one or more locations. Health care plan involving contracts with physicians organized as a partnership, professional corporation, or other legal association. It can also refer to an HMO model in which the HMO contracts with one or more medical groups to provide services to members. In either case, the payer or health plan pays the medical group, which is, in turn, is responsible for compensating physicians. The medical group may also be responsible for paying or contracting with hospitals and other providers.

Group Practice - A group of persons licensed to practice medicine in the State, who, as their principal professional activity, and as a group responsibility, engage or undertake to engage in the coordinated practice of their profession primarily in one or more group practice facilities, and who in their connection share common overhead expenses if and to the extent such expenses are paid by members of the group, medical and other records, and substantial portions of the equipment and the professional, technical, and administrative staffs. Group practices use the acronyms PA, IPA, MSO and others. Group practices are far more common now than a decade ago because physicians seek to lower costs, increase contracting power and share payer contracts.

H

Health Insurance Portability and Accountability Act (HIPAA) - HIPAA seeks to establish standardized mechanisms for electronic data interchange (EDI), security, and confidentiality of all healthcare-related data.
Read more….

Health Level 7  (HL7) - Formed in the United States in 1987, HL7 has the goal of developing an international set of open standards for data format and content that allows different health information systems to easily and effectively communicate with one another.
Read more….


HCFA 1500 - The Health Care Finance Administration's standard form for submitting provider service claims to third party companies or insurance carriers. HCFA 1500 is now called CMS 1500.
Health information exchange - is defined as the mobilization of healthcare information electronically across organizations within a region or community. HIE provides the capability to electronically move clinical information between disparate healthcare information systems while maintaining the meaning of the information being exchanged. The goal of HIE is to facilitate access to and retrieval of clinical data to provide safer, more timely, efficient, effective, equitable, patient-centered care.

HCFA-1450 - HCFA's name for the institutional uniform claim form, or UB-92.
Healthcare Financing Administration(HCFA) - Former name of the government agency now called the Centers for Medicare & Medicaid Services.

Health Care, Healthcare - Care, services, and supplies related to the health of an individual. Health care includes preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, among other services. Healthcare also includes the sale and dispensing of prescription drugs or devices.

Health Care Clearinghouse - A public or private entity that does either of the following (Entities, including but not limited to, billing services, repricing companies, community health management information systems or community health information systems, and “value-added” networks and switches are health care clearinghouses if they perform these functions): 1) Processes or facilitates the processing of information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction; 2) Receives a standard transaction from another entity and processes or facilitates the processing of information into nonstandard format or nonstandard data content for a receiving entity. This term is used in the HIPAA rules.

HIPAA and CPT - The Administrative Simplification Section of the Health Insurance Portability and Accountability Act (HIPAA) requires the Department of Health and Human Services to name national standards for electronic transaction of health care information. This includes transactions and code sets, national provider identifier, national employer identifier, security, and privacy. The FinalRule for transactions and code sets was issued on August 17, 2000. The rule names CPT (including codes and modifiers) and HCPCS as the procedure code set for:

 
Health Care Provider – is a person who is trained and licensed to give health care. It could also be a place licensed to give health care. Doctors, nurses, hospitals, skilled nursing facilities, some assisted living facilities and certain kinds of home health agencies are examples of health care providers.

Health Insurance Claims Number - The number assigned by the Social Security Administration to an individual identifying him/her as a Medicare beneficiary. This number is shown on the beneficiary's insurance card and is used in processing Medicare claims for that beneficiary.

Health Insurance Portability & Accountability Act (HIPAA)- law passed in 1996, which is also sometimes called the "Kassebaum-Kennedy" law. This law expands your health care coverage if you have lost your job, or if you move from one job to another, HIPAA protects you and your family if you have: pre-existing medical conditions, and/or problems getting health coverage, and you think it is based on past or present health. HIPAA also limits how companies can use your pre-existing medical conditions to keep you from getting health insurance coverage; usually gives you credit for health coverage you have had in the past; may give you special help with group health coverage when you lose coverage or have a new dependent; and generally, guarantees your right to renew your health coverage. HIPAA does not replace the states' roles as primary regulators of insurance

Health Insuring Organization – is an entity that provides for or arranges for the provision of care and contracts on a prepaid capitated risk basis to provide a comprehensive set of services.

Health Level Seven - An ANSI-accredited group that defines standards for the cross-platform exchange of information within a health care organization. HL7 is responsible for specifying the Level Seven OSI standards for the health industry. Health Level Seven (HL7) is an American National Standards Institute (ANSI) accredited standards organization and a standard. As an organization, HL7's mission is to provide standards for: Exchange Management and Integration of data that support clinical patient care. The standard defines the protocol for exchanging clinical data between diverse healthcare information systems. HL7 version 2.X commonly specifies the majority of the interface information without difficulties, albeit with a few limitations. The current version, HL7 2.4, has established itself as a nearly universal standard for clinical and administrative data. Version 3.0, currently in draft, will further extend the functionality of health data exchange.

Health Plan - An entity that assumes the risk of paying for medical treatments, i.e. uninsured patient, self-insured employer, payer, or HMO.

Healthcare Common Procedural Coding System - A medical code set that identifies health care procedures, equipment, and supplies for claim submission purposes. It has been selected for use in the HIPAA transactions. HCPCS Level I contains numeric CPT codes which are maintained by the AMA. HCPCS Level II contains alphanumeric codes used to identify various items and services that are not included in the CPT medical code set. These are maintained by HCFA, the BCBSA, and the HIPAA. HCPCS Level III contains alphanumeric codes that are assigned by Medicaid state agencies to identify additional items and services not included in levels I or II. These are usually called "local codes", and must have "W", "X", "Y", or "Z" in the first position. HCPCS Procedure Modifier Codes can be used with all three levels, with the WA - ZY range used for locally assigned procedure modifiers.

Home Health Care - Healthcare services rendered to a member in their home in lieu of confinement in a hospital or skilled nursing facility. Care must be under the supervision of a registered professional nurse. This type of care may include physical, occupation or speech therapy, medical supplies and medication prescribed by a doctor.

Home Infusion Therapy - The administration of intravenous drug therapy in the home. Home infusion therapy includes the following services: solutions and pharmaceutical additives; pharmacy compounding and dispensing services; durable medical equipment; ancillary medical supplies; and, nursing services.

Hospital Coinsurance - or the 61st through 90th day of hospitalization in a benefit period, a daily amount for which the beneficiary is responsible, equal to one-fourth of the inpatient hospital deductible; for lifetime reserve days, a daily amount for which the beneficiary is responsible, equal to one-half of the inpatient hospital deductible (See "Lifetime reserve days")

Hospital Insurance - The Medicare proram that covers specified inpatient hospital services; post hospital skilled nursing care, home health services, and hospice care for aged and disabled individuals who meet the eligibility requirements. Also known as Medicare Part A.

hospital Insurance (Part A) The part of Medicare that pays for inpatient hospital stays, care in a skilled nursing facility, hospice care and some home health care.
Hospice - A facility or service that provides care for the terminally ill patient and who provides support to the family. The care, primarily for pain control and symptom relief, can be provided in the home or in an inpatient setting.

Hospital - An institution whose primary function is to provide inpatient services, diagnostic and therapeutic, for a variety of medical conditions, both surgical and non-surgical. In addition, most hospitals provide some outpatient services, particularly emergency care.

Hospital Affiliation – refers to t he hospital in which the provider is associated.

Home Health Care - Healthcare services rendered to a member in their home in lieu of confinement in a hospital or skilled nursing facility. Care must be under the supervision of a registered professional nurse. This type of care may include physical, occupation or speech therapy, medical supplies and medication prescribed by a doctor.

Home Infusion Therapy – refers to t he administration of intravenous drug therapy in the home. Home infusion therapy includes the following services: solutions and pharmaceutical additives; pharmacy compounding and dispensing services; durable medical equipment; ancillary medical supplies; and, nursing services.

Healthcare Provider Taxonomy Codes - An administrative code set that classifies health care providers by type and area of specialization. The code set will be used in certain adopted transactions. (Note: A given provider may have more than one Healthcare Provider Taxonomy Code.)

Health Insurance Purchasing Cooperatives (HIPC) - Public or private organizations that secure health insurance coverage for the workers of all member employers. The goal of these organizations is to consolidate purchasing responsibilities to obtain greater bargaining clout with health insurers, plans and providers, to reduce the administrative costs of buying, selling and managing insurance policies. Private cooperatives are usually voluntary associations of employers in a similar geographic region who band together to purchase insurance for their employees. Public cooperatives are established by state governments to purchase insurance for public employees, Medicaid beneficiaries, and other designated populations. See Purchasing Alliances.

Health Insuring Organization (HIO) – is an organization that contracts with a state Medicaid agency as a fiscal intermediary.

I

Incurred But Not Reported (IBNR) - Refers to a financial accounting of all services that have been performed but, as a result of a short period of time, have not been invoiced or recorded. It represents the estimates of the cost for medical services provided for which a claim has not yet been filed. Refers to claims that reflect services already delivered, but, for whatever reason, have not yet been reimbursed. These are bills "in the pipeline." This is a crucial concept for proactive providers who are beginning to explore arrangements that put them in the role of adjudicating claims--as the result, perhaps, of operating in a sub-capitated system. Failure to account for these potential claims could lead to some very bad decisions. Good administrative operations have fairly sophisticated mathematical models to estimate this amount at any given time.

Indemnity - Health insurance benefits provided in the form of cash payments rather than services. Insurance program in which covered person is reimbursed for covered expenses. An indemnity insurance contract usually defines the maximum amounts that will be paid for covered services. Indemnity insurance plans may have a PPO option, UR and case management features, or include a network or other preferred provider restrictions, but will not have an HMO plan. Indemnity is the traditional form of insurance. Normally when one thinks of indemnity health coverage, one is thinking of the type of plan that does not require “pre-certification” and does not restrict the physicians, drugs or hospitals that will be paid for. Indemnity coverage usually has higher premiums. Indemnity insurance plans are the classic plans - where few restrictions are in place. With these plans, members are normally able to use the providers of their choice and are able to make independent decisions about the type of care they wish to receive. Usually these plans include co-payments, deductibles and maximums but rarely require case management certification or approvals. Managed care, particularly HMO and capitation, has evolved away from the indemnity method. Yet, many people are still covered under indemnity plans.

Indemnity Carrier - Usually an insurance company or insurance group that provides marketing, management, claims payment and review, and agrees to assume risk for its subscribers at some pre-determined rate.

Indemnity Wraparound Policy – Refers to an out-of-plan product that an HMO offers through an agreement with an insurance company.

Indemnity Plan (Indemnity health insurance) - A plan that reimburses physicians for services performed, or beneficiaries for medical expenses incurred. Such plans are contrasted with group health plans, which provide service benefits through group medical practice.

Independent Practice Association (IPA) or Organization (IPO) - A delivery model in which the HMO contracts with a physician organization, which in turn contracts with individual physicians. The IPA physicians practice in their own offices and continue to also see their FFS patients. The HMO reimburses the IPA on a capitated basis; however, the IPA may reimburse the physicians on an FFS or capitated basis.

Individual (Independent) Practice Association (IPA) - An organized form of prepaid medical practice in which participating physicians remain in their independent office settings, seeing both enrollees of the IPA and private-pay patients. Participating physicians may be reimbursed by the IPA on a fee-for-service basis or a capitation basis. Sometimes thought of as an HMO model in which the HMO contracts with a physician organization that in turn contracts with individual physicians. The IPA physicians provide care to HMO members from their private offices and continue to see their fee-for-service patients.

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM, ICD-10-CM) - This is the universal coding method used to document the incidence of disease, injury, mortality and illness. A diagnosis and procedure classification system designed to facilitate collection of uniform and comparable health information. The ICD-9-CM was issued in 1979. This system is used to group patients into DRGs, prepare hospital and physician billings and prepare cost reports. Classification of disease by diagnosis codified into six-digit numbers. See also coding.

J

J-Codes - A subset of the HCPCS Level II code set with a high-order value of "J" that has been used to identify certain drugs and other items.

Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) - Formerly called JCAH, or Joint Commission on Accreditation of Hospitals, this is the peer review organization which provides the primary review of hospitals and healthcare providers. Many insurance companies require providers to have this accreditation in order to seek 3rd party payment, although, many small hospitals cannot afford the cost of accreditation. JCAHO surveys organizations frequently, often unannounced, sending in a medical and administrative team to review policies, patient records, professional credentialing procedures, governance and quality improvement programs. JCAHO revises its "standards" annually.

K

 Key Contributor Plan - This refers to a little known performance-based program with incentives for the purpose of attracting, motivating and retaining key individuals or small groups.

kyphosis - a disorder of the spine in which the spine shows evidence of a forward curvature of the backbone in the upper back area, giving a person a "humpback" appearance.

L

 Large Claim Pooling - System that isolates claims above a certain level and charges them to a pool funded by charges of all groups who share the pool. Designed to help stabilize significant premium fluctuations.

Large Group - A large pool of individuals for which health coverage is provided by the group sponsor. A large group may be defined as more than 250, 500, 1,000, or some other number of members, depending on the MCO.

Lifetime Maximum - The maximum amount of benefits your policy will pay for covered expenses over the course of your lifetime.

Limiting Charge - The maximum amount that a non-participating physician is permitted to charge a Medicare beneficiary for a particularly defined procedure or bundled service. These limits are published by the individual state intermediaries for Medicare and CMS and are usually combined in reports with the allowed charges and regional payment schedules. In 1993, the limiting charge was set at 115 percent of the Medicare-allowed charge. The limiting charge is 15% over Medicare’s approved amount. The limiting charge only applies to certain services and doesn’t apply to supplies or equipment and may not reflect what the physician will be paid.

M

 Managed Health Care Plan - An arrangement that integrates financing and management with the delivery of health care services to an enrolled population. It employs or contracts with an organized system of providers that delivers services and frequently shares financial risk.

Medicare - The federal health insurance program for: people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD). Medical bills are paid from trust funds, which those covered, have paid into. It serves people over 65 primarily, whatever their income; and serves younger disabled people and dialysis patients. Patients pay part of costs through deductibles for hospital and other costs. Small monthly premiums are required for non-hospital coverage. Medicare is a federal program. It is basically the same everywhere in the United States and is run by the Health Care Financing Administration, an agency of the federal government.

Medicaid - An assistance program. Medical bills are paid from federal, state and local tax funds. It serves low-income people of every age. Patients usually pay no part of costs for covered medical expenses. A small co-payment is sometimes required. Medicaid is a federal-state program. It varies from state to state. It is run by state and local governments within federal guidelines.

Medicare Carrier - A private company that contracts with Medicare to pay Part B bills.

Medical Code Sets - Codes that characterize a medical condition or treatment. These code sets are usually maintained by professional societies and public health organizations. Compare to administrative code sets.

Medicare Contractor - Medicare Part A Fiscal Intermediary (institutional), a Medicare Part B Carrier (professional), or a Medicare Durable Medical Equipment Regional Carrier (DMERC)

Medicare Coverage - Made up of two parts: Hospital Insurance (Part A) and
Medical Insurance (Part B)

Medicare Part-A (Hospital Insurance) Hospital insurance that pays for inpatient hospital stays, specialized care in a skilled nursing facility, hospital care and some home health care.

Medicare Part-B Carrier A Medicare contractor that administers the Medicare Part B (Professional) benefits for a given region.

Medicare Supplement Contract - Health insurance policy designed to supplement Medicare, beginning at the point Medicare coverage ceases for a particular service. Also referred to as a Medigap policy. Medical insurance that helps pay for: Doctor's services Outpatient hospital care, and Other medical services that are not covered by Part A

Medicare Part-A Fiscal Intermediary - A Medicare contractor that administers the Medicare Part A (institutional) benefits for a given region

Member - A person, including eligible covered dependents, that has coverage with a plan sponsor using Insurance company.

Member ID Number - A unique number that identifies the person as a member with the insurance company . Many times the member's ID is the insured's social security number.

Multiple Option Plan - Health care plan that lets employees or members choose their own plan from a group of options, such as HMO, PPO or major medical plan. See also Cafeteria Plan or Flexible Benefits Plan.

Multi-Specialty Group - A group of doctors who represent various medical specialties and who work together in a group practice.

N

 National Claims History System (NCH) - A CMS data reporting system that combines both Part A and Part B claims in a common file. The NCH system became fully operational in 1991.

National Council for Prescription Drug Programs - An ANSI-accredited group that maintains a number of standard formats for use by the retail pharmacy industry, some of which have been adopted as HIPAA standards.

National Drug Code (NDC) - A medical code set maintained by the Food and Drug Administration that contains codes for drugs that are FDA-approved. The Secretary of HHS adopted this code set as the standard for reporting drugs and biologics on standard transactions. Classification system for drug identification, similar to UPC code.

National Provider Identifier - A system for uniquely identifying all providers of health care services, supplies, and equipment. A term proposed by the Secretary of HHS as the standard identifier for health care providers.

Network - The group of physicians, hospital, and other medial care providers that a specific plan has contracted with to deliver medical services to its members.

Network Provider - A doctor, hospital or other healthcare provider who has entered into an agreement with healthcare insurance group to provide healthcare services to members for a negotiated rate of reimbursement.

Network Model HMO - This type of HMO contracts with more than one physician group and may contract with single or multi-specialty groups as well as hospitals and other health care providers. A health plan that contracts with multiple physician groups to deliver health care to members. Generally limited to large single or multi-specialty groups. Distinguished from group model plans that contract with a single medical group, IPA's that contract through an intermediary, and direct contract model plans that contract with individual physicians in the community.

Nurse Practitioner(NP) - A registered nurse qualified and specially trained to provide primary care, including primary health care in homes and in ambulatory care facilities, long-term care facilities, and other health care institutions. Normally, NPs are licensed and possess masters degrees. Nurse practitioners generally function under the supervision of a physician but not necessarily in his/her or her presence. In some states, NPs are able to provide basic medical services without requiring MD or DO supervision. They are either salaried or reimbursed on a fee-for-service basis. See also Midlevel Practitioners.

O

 Occupational Health - OSHA, county health departments and regulatory bodies oversee occupational health hazards in workplaces, including hospitals. Occupational health programs include the employer activities undertaken to protect and promote the health and safety of employees in the workplace, including minimizing exposure to hazardous substances, evaluating work practices and environments to reduce injury, and reducing or eliminating other health threats. Many health providers offer occupational health consultations as well as occupational health screenings, treatments and case-management. Employers and health providers often enter agreements whereby health providers will provide these services as well as managed the related workers compensation case management and rehabilitation programs.

Open Access - A term describing a member's ability to self-refer for specialty care. Open access arrangements allow a member to see a participating provider without a referral from another doctor. Health plan members' abilities, rights or invitation to self refer for specialty care. Also called Open Panel.

Original Medicare Plan - A fee-for-service health plan that lets enrollees go to any doctor, hospital, or other health care supplier who accepts Medicare and is accepting new Medicare patients. The enrollee must pay the deductible. Medicare pays its share of the Medicare-approved amount, and the enrollee pays a share (coinsurance). In some cases the enrollee may be charged more than the Medicare-approved amount. The Original Medicare Plan has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).

Out of Area Benefits - Benefits supplied to a patient by a payer or managed care organization when the patient needs services while outside the geographic area of the network. MCOs often attempt to negotiate a case-by-case discount with providers when patients utilize their services while "out of area".

Out of Pocket Expenses , Out of Pocket Costs - Dollar amounts set by MCOs that limit the amount a member has to pay out of his or her own pocket for particular healthcare services during a particular time period.Costs borne by the member that are not covered by health care plan. Portion of health services or health costs that must be paid for by the plan member, including deductibles, co-payments and co-insurance. In the age of managed care, out of pocket expenses can also refer to the payment of services not covered by or approved for reimbursement by the health plan.

Outpatient Care - Care given a person who is not bedridden. Also called ambulatory care. Many surgeries and treatments are now provided on an outpatient basis, while previously they had been considered reason for inpatient hospitalization. Some say this is the fastest growing segment of healthcare.

Outpatient Hospital Care - Medical or surgical care furnished by a hospital to a patient if that patient has not been admitted as an inpatient but is registered on hospital records as an outpatient. If a doctor orders that a patient be placed under observation, it may be considered outpatient care, even if the patient stays under observation overnight.

P

 Patient Liability - The dollar amount that an insured is legally obligated to pay for services rendered by a provider. These may include co-payments, deductibles and payments for uncovered services.

Part A Medicare - Refers to the inpatient portion of benefits under the Medicare Program, covering beneficiaries for inpatient hospital, home health, hospice, and limited skilled nursing facility services. Beneficiaries are responsible for deductibles and copayments. Part A services are financed by the Medicare HI Trust Fund, which consists of Medicare tax payments. See also Medicare.

 Part B Medicare - Refers to the outpatient benefits of Medicare. Medicare Supplementary Medical Insurance (SMI) under Part B of Title XVII of the Social Security Act covers Medicare beneficiaries for physician services, medical supplies, and other outpatient treatment. Beneficiaries are responsible for monthly premiums, copayments, deductibles, and balance billing. Part B services are financed by a combination of enrollee premiums and general tax revenues. See also Medicare.

 Part D Medicare - A stand-alone drug plan, offered by insurers and other private companies to beneficiaries that receive their Medicare Part A and/or B benefits through the Original Medicare Plan; Medicare Private Fee-for-Service Plans that don’t offer prescription drug coverage; and Medicare Cost Plans offering Medicare prescription drug coverage. These stand-alone plans add prescription drug coverage to the Original Medicare Plan and to some Medicare Cost Plans and Medicare Private Fee-for-Service Plans. Managed by commercial and private entities, these PDPs are a type of managed care and discounting. When people join a Medicare Prescription Drug Plan, they use the plan member cards that are received from the plans when they go to the pharmacies to purchase prescriptions. When they use their cards, they will normally get discounts on their prescriptions, provided that the drugs are on the approved or covered lists and they are not operating within the "donut hole". Costs will vary depending on recipients' financial situations and which Medicare Prescription Drug Plans they chose. If an individual has limited income and resources, he or she may get extra help to cover prescription drugs for little or no cost. See also Medicare and Prescription Drug Plan.

 Partial Capitation - A contract between a payer and a sub-capitor, provider or other payer whereby payments made are a combination of capitated premiums and fee for service payments. The proportion of the ratios determines the amount of risk. Sometimes certain outliers are paid as fee for service (difficult childbirth, cardiac care, cancer) while routine care (preventative, family, simple surgeries and common diagnoses) are capitated.

 Partial Risk Contract - A contract between a purchaser and a health plan, in which only part of the financial risk is transferred from the purchaser to the plan. Forms of this are often seen in "self-funded" plans, competitive bidding arrangements and new health plans.

 Participating Physician - A primary care physician in practice in the payer's managed care service area who has entered into a contract.

Participating Provider - Any provider licensed in the state of provision and contracted with an insurer. Usually this refers to providers who are a part of a network. That network would be a panel of participating providers. Payers assemble their own provider panels.

 Primary Care Physician (PCP) - A "generalist" such as a family practitioner, pediatrician, internist, or obstetrician. In a managed care organization, a primary care physician is accountable for the total health services of enrollees including referrals, procedures and hospitalization.

 Primary Care Provider (PCP) - The provider that serves as the initial interface between the member and the medical care system. The PCP is usually a physician, selected by the member upon enrollment, who is trained in one of the primary care specialties who treats and is responsible for coordinating the treatment of members assigned to his/her plan.

Prior Authorization for Drug Benefits - The process for obtaining drug coverage from a prescription benefit manager. If a physician feels that, for medically necessary reasons, a patient needs a certain medication that is not on the patient’s drug formulary or requires prior authorization, the prescribing physician may request an exception by contacting the patient’s prescription benefit manager. Prior authorization may be required for a number of reasons, such as the potential toxicity or the potential abuse of the drug. Prior authorization is similar to prior approval but typically used only in reference to drug benefits. Prior authorization is designed to encourage appropriate drug use and to assist in reducing drug benefit costs.

 Q

 Quality Assurance Reform Initiative (QARI) - A process developed by the Health Care Financing Administration (now called CMS) to develop a health care quality improvement system for Medicaid managed care plans. The Quality Assurance Reform Initiative was unveiled in 1993 to assist States in the development of continuous quality improvement systems, external quality assurance programs, internal quality assurance programs, and focused clinical studies.

 Quality Improvement Organization (Medicare) - Groups of practicing doctors and other health care experts that are paid by the federal government to check and improve the care given to Medicare patients. They must review patient complaints about the quality of care given by: inpatient hospitals, hospital outpatient departments, hospital emergency rooms, skilled nursing facilities, home health agencies, Private Fee-for-Service Plans, and ambulatory surgical centers. These doctors also review fast-track termination decisions in comprehensive outpatient rehabilitation facilities, skilled nursing facilities, and home health and hospice settings for people in Medicare Health Plans.

 Quality Improvement System for Managed Care (QISMC) - A CMS program designed to strengthen MCOs' efforts to protect and improve the health and satisfaction of Medicare and Medicaid enrollees.

 R

 Rate Band - The allowable variation in insurance premiums as defined in state regulations. Acceptable variation may be expressed as a ratio from highest to lowest (e.g., 3:1) or as a percent from the community rate (e.g., +/-20%). Usually based on risk factors such as age, gender, occupation or residence.

Referral - The process of sending a patient from one practitioner to another for health care services. Health Plans may require that designated primary care providers authorize a referral for coverage of specialty services. Normally, this type of referral means a written order from the enrollee's primary care doctor for the enrollee to see a specialist or get certain services. In many HMOs or Health Plans, an enrollee must get a referral before the enrollee can get care from anyone except the primary care doctor. Without a formal referral, the plan may not pay for the care. See also Primary Care Physician.

 Referral Center , also called Triage, Call Center, 24 Hour Certification or 1-800 - This is a mechanism established by health plans to direct patients to approved hospitals and doctors. Often the Referral Center serves a UR function and certified or pre-certifies the care. These centers are also used by hospitals to refer patients to certain doctors, reduce use of the emergency room or to provide follow-up patient contact. Manage care organizations utilize these centers as their central hub of communications with patients and providers at the time of service. See also Pre-Certification, Utilization Review, Prior Approval or Case Management.

 Referral Services - Medical Services arranged for by the physician and provided outside the physician's office other than Hospital Services.

Registered Nurses (RN) - Registered nurses are responsible for carrying out the physician's instructions. They supervise practical nurses and other auxiliary personnel who perform routine care and treatment of patients. Registered nurses provide nursing care to patients or perform specialized duties in a variety of settings from hospital and clinics to schools and public health departments. A license to practice nursing is required in all states. For licensure as a registered nurse (R.N.), an applicant must have graduated from a school of nursing approved by the state board for nursing and have passed a state board examination

S

 Secondary Care - Services provided by medical specialists who generally do not have first contact with patients (e.g., cardiologist, urologists, dermatologists). In the U.S., however, there has been a trend toward self-referral by patients for these services, rather than referral by primary care providers. This is quite different from the practice in England, for example, where all patients must first seek care from primary care providers and are then referred to secondary and/or tertiary providers, as needed.

 Secondary Coverage - Health plan that pays costs not covered by primary coverage under coordination of benefits rules. Any insurance that supplements Medicare coverage. The three main sources for secondary insurance are employers, privately purchased Medigap plans, and Medicaid. See Secondary Payer.

Secondary Payer - An insurance policy, plan, or program that pays second on a claim for medical care. This could be Medicare, Medicaid, or other insurance depending on the situation and may or may not be Supplemental Insurance.

 Self-Funding or Self-Funded Plan - Employer or organization assumes complete responsibility for health care losses of its covered employees. This usually includes setting up a fund against which claim payments are drawn and claims processing is often handled through an administrative services contract with an independent organization. In this case, the employer does not pay premiums to an insurance carrier, but, rather pays administrative costs to the insurance company or health plan, and, in essence, treats them as a third party administrator (TPA) only. However, the employee may not be able to detect any difference because the plan description and membership card may carry the name of the insurance company not the employer.

 Self-Insurance or Self-Insured - An individual or organization that assumes the financial risk of paying for health care. This term is usually used to describe the type of insurance that an employer provides. When an employer is self-insured, this means that the payer or managed care company manages the employer's funds whether than requiring the employer to pay premiums. Many employers choose to self-insure because they are then exempted from certain insurance laws and also think that they will spend less money in the short run. Employers assume the risks involved and also have full rights to all insurance claim information. Typically, the self-insured employer is a large employer. The employees or patients will not be able to discern if their employer is self-insured easily since all paperwork or benefits cards usually contain the name of the insurance company.

 Specialist - A doctor who treats only certain parts of the body, certain health problems, or certain age groups. Normally, a specialist has received advanced training in a specialty field. For example, some doctors treat only heart problems. Some health plans require enrollees to obtain a referral from a primary care provider prior to seeing a specialist in order for the specialist care to be reimbursed. Also see Referral or Primary Care Physician.

Specialty Health Maintenance Organization (Specialty HMO) - An organization that uses an HMO model to provide healthcare services in a subset or single specialty of medical care. Also see Carve-Out.

State Children's Health Insurance Program (SCHIP) - Under Title XXI of the Balanced Budget Act of 1997, the availability of health insurance for children with no insurance or for children from low-income families was expanded by the creation of SCHIP. SCHIPs operate as part of a state's Medicaid program. Although Medicaid has made great strides in enrolling low-income children, significant numbers of children remain uninsured. From 1988 to 1998, the proportion of children insured through Medicaid increased from 15.6% to 19.8%. At the same time, however, the percentage of children without health insurance increased from 13.1% to 15.4%. The increase in uninsured children is mostly the result of fewer children being covered by employer-sponsored health insurance. The Balanced Budget Act of 1997 created a new children's health insurance program called the State Children's Health Insurance Program. This program gave each state permission to offer health insurance for children, up to age 19, who are not already insured. SCHIP is a state administered program and each state sets its own guidelines regarding eligibility and services.

Summary Plan Description (SPD) - In self-funded plans, a written explanation of the eligibility for and benefits available to employees required by ERISA.

 T

 Third-Party Payment - Payment by a financial agent such as an HMO, insurance company or government rather than direct payment by the patient for medical care services. The payment for health care when the beneficiary is not making payment, in whole or in part, in his own behalf.

 Third-Party Payer - Any organization, public or private that pays or insures health or medical expenses on behalf of beneficiaries or recipients. An individual pays a premium for such coverage in all private and in some public programs; the payer organization then pays bills on the individual's behalf. Such payments are called third-party payments and are distinguished by the separation among the individual receiving the service (the first party), the individual or institution providing it (the second party), and the organization paying for it (third party).

 Tracking of Disclosures - The HIPAA Privacy Rule gives individuals the right to request an accounting of disclosures of protected health information over the previous six years. If an individual authorizes uses or disclosures for research, the disclosures do not need to be tracked, but disclosures must be tracked if the researcher receives an IRB-approved waiver of authorization. The accounting of disclosures generally must include: the date of the disclosure, the name of the entity or person (and address if known) who received the protected health information, a brief description of the information disclosed, and a brief statement of the purpose of the disclosure. The Rule allows for an alternative tracking option is available for research involving 50 or more people.

TRICARE - A health care program for active duty and retired uniformed services members and their families.

 TRICARE Extra - A reduced fee-for-service (FFS) plan similar to the network portion of a PPO.

 TRICARE for Life (TFL) - Expanded medical coverage available to Medicare-eligible uniformed services retirees age 65 or older, their eligible family members and survivors, and certain former spouses.

 TRICARE Prime - An enrollment-based managed care option designed to provide coordinated care managed by a primary care manager, who is similar to a primary care provider in a commercial HMO.

 TRICARE Standard - A fee-for-service plan that allows participants to use TRICARE authorized providers or non-network providers.

 Triple Option Plan - A plan (usually offered by a single carrier or a joint venture between two or more carriers) that gives subscribers or employees a choice among HMO, PPO and traditional indemnity plans.

 Two-Tier Copayment Structure - A pharmacy benefit copayment system under which a member is required to pay one copayment amount for a generic drug and a higher copayment amount for a brand-name drug.

 U

 UB-92 (Uniform Billing Code of 1992) - Bill form used to submit hospital insurance claims for payment by third parties. Similar to legacy HCFA 1500, but reserved for the inpatient component of health services. An electronic format of the CMS-1450 paper claim form that has been in general use since 1993.

 Uncompensated Care - Service provided by physicians and hospitals for which no payment is received from the patient or from third-party payers. Some costs for these services may be covered through cost-shifting. Not all uncompensated care results from charity care. It also includes bad debts from persons who are not classified as charity cases but who are unable or unwilling to pay their bill.

 Underinsured - People with public or private insurance policies that do not cover all necessary health care services, resulting in out-of-pocket expenses that exceed their ability to pay.

 V

 Variable Contribution Health Plan – In contrast to a fixed contribution plan, a variable contribution involves employers committing to a specified level of benefits funding for its employees, regardless of the actual benefit price. Employers are thus locked into variable contribution arrangements because they are committed to funding a certain benefit structure without knowing what the future costs may be if premiums are raised.

Volume Performance Standard (VPS) System - The VPS provides a mechanism to adjust fee updates for the Medicare Fee Schedule based on how annual increases in actual expenditures compare with previously determined performance standard rates of increase.

W

 Waiver of Authorization – Under HIPAA, under limited circumstances, a waiver of the requirement for authorization for use or disclosure of private health information may be obtained from the IRB by the researcher. A waiver of authorization can be approved only if specific criteria have been met.

Workers' Compensation - Insurance that employers are required to have to cover employees who get sick or injured on the job.A state-mandated program providing insurance coverage for work-related injuries and disabilities. Several states have either enacted or are considering changes to the Workers Compensation Laws to allow employers to cover occupational injuries and illnesses within their own existing group medical plans. Some employers pay premiums to the state or to insurance companies for this coverage. Others are self-funded and use third party case management or administrative services to manage the processes.