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 ]
Access: The patient's ability to obtain medical care. The ease of access is determined by such components as the availability of medical services and their acceptability to the patient, the location of health care facilities, transportation, hours of operation and cost of care. Access describes an individual's ability to obtain appropriate health care services. Barriers to access can be financial (insufficient monetary resources), geographic (distance to providers), organizational (lack of available providers) and sociological (e.g., discrimination, language barriers). Efforts to improve access often focus on providing/improving health coverage.
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.
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.
Addendum: Text that is added to a document after it has been finalized.
Adjudication: Processing claims according to contract.
Alerts: Pop-ups or reminders. An automated warning system such a clinical alerts, preventive health maintenance, medication interactions etc.
Allergy List: This is a list of all the patient’s allergies.
Allowed Charge: is the amount, that Medicare approves for payment to a physician, but this amount may not match the amount the physician gets paid by Medicare (due to co-pay or deductibles) and usually does not match what the physician charges patients. Medicare normally pays 80 percent of the approved charge and the beneficiary pays the remaining 20 percent. The allowed charge for a nonparticipating physician is 95 percent of that for a participating physician. Non-participating physicians may bill beneficiaries for an additional amount above the allowed charge. The CMS intermediary in each state publishes these rates.
Allowable Costs: Covered expenses within a given health plan reflecting Items or elements of an institution's costs, which is reimbursable under a payment formula. Both Medicare and Medicaid reimburse hospitals on the basis of only certain costs. Allowable costs may exclude, for example, luxury travel or marketing. CMS publishes an extensive list of rules governing these costs and provides software for determining costs. Normally the costs which are not reasonable expenditures, which are unnecessary, which are for the efficient delivery of health services to persons covered under the program in question and are not reimbursed. The most common form of cost reimbursement is the "cost report" methodology used for DRG-exempt services, such as many out-patient hospital based programs, long-term care and skilled nursing units, physical rehab, psychiatric and substance abuse inpatient programs. Some specialty hospitals receive all of their CMS reimbursement as cost based reimbursement.
Ambulatory Care: Medical care provided on an outpatient basis.
Annotator: A system function that allows an explanatory note or diagram to be added to an image.
Appointment Scheduler: The appointment scheduler which takes charge of your appointment tracking, fixing and blocking.
ASP: Application Service Provider (a.k.a. - Web based) A remotely hosted EMR program and database.  Advantages are reduced initial investment in hardware and reduced responsibility in maintenance of server and data.  The disadvantages are completely dependent on internet connectivity and on the server host speed to access images, scanned documents, etc. Long term cost is frequently greater.
Authentication: The verification of the identity of a person or process.
Authorization: Any document designating any permission. 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, she/he may not be able to receive the intended treatment; the subject's signature and date.
[ 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.
Balance Forward: An accounting reference for the amount outstanding on an account transferred from another billing system. Primarily used during data migration from your legacy system to your new Medinformatix system
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.
Beneficiary (Also eligible; enrollee; member): Individual who is either using or eligible to use insurance benefits, including health insurance benefits, under an insurance contract. It describes any person eligible as either a subscriber or a dependent for a managed care service in accordance with a contract. An individual who receives benefits from or is covered by an insurance policy or other health care financing program.
Billed Claims: Fees submitted by a health care provider for services rendered to a covered person. Fees billed and fees paid are rarely synonymous.
BMI (Body Mass Index): Calculation based on height and weight. This is similar to percent body fat and demonstrates how much effect a person's weight is on their health.
BSA(body surface area): In physiology and medicine, the body surface area (BSA) is the measured or calculated surface of a human body. For many clinical purposes BSA is a better indicator of metabolic mass than body weight because it is less affected by abnormal adipose mass. Estimation of BSA is simpler than many measures of volume.
[ C ]
Continuity of Care Record (CCR): The continuity of care record is a standardized electronic snapshot of a patient’s medical, insurance, and demographic information at any given point in time. Standardization was established by the Healthcare Information and Management Systems Society (HIMSS), the American Academy of Family Physicians (AAFP), other medical societies, and vendors and others in the healthcare informatics industry. Data are transmitted in XML, a standard transmission language, enabling a patient’s CCR to be shared among any number of providers. Each provider may make additions or changes to the information in a patient’s CCR, which is kept up-to-date in real time. While not all of the patient’s information is in the CCR–distinguishing it from most full-function electronic PHRs–critical information is available that may be useful in referrals, travel situations, and emergencies
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.
Case Management: 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. Case management is the 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 Severity: A measure of intensity or gravity of a given condition or diagnosis for a patient. May have direct correlation with the amount of service provided and the associated costs or payments allowed.
Chain of Trust Agreement: Referred to in HIPAA rules, this is a contract needed to extend the responsibility to protect health care data across a series of sub-contractual relationships.
CHAMPUS: Civilian Health and Medical Program of the Uniformed Services.
Charges: These are the published prices of services provided by a facility. CMS requires hospitals to apply the same schedule of charges to all patients, regardless of the expected sources or amount of payment. Controversy exists today because of the often wide disparity between published prices and contract prices. The majority of payers, including Medicare and Medicaid, are becoming managed by health plans that negotiate rates lower than published prices. Often these negotiated rates average 40% to 60% of the published rates and may be all-inclusive bundled rates.
Chart Note: A document, written by the clinician or provider, which describes the details of a patient’s encounter. It is sometimes referred to as a progress note.
Chief Complaint (CC) Reason for Consultation (RFC): for recording a patient’s disease symptoms.
Client/Server architecture: An information-transmission arrangement, in which a client program sends a request to a server. When the server receives the request, it disconnects from the client and processes the request. When the request is processed, the server reconnects to the client program and the information is transferred to the client. This usually implies that the server is located on site as opposed to the ASP (Application Server Provider) architecture.
Clinical Data Repository (CDR):A real-time database that consolidates data from a variety of clinical sources to present a unified view of a single patient. It is optimized to allow clinicians to retrieve data for a single patient rather than to identify a population of patients with common characteristics or to facilitate the management of a specific clinical department.
Clinical Decision support system (CDSS): A clinical decision support system (CDSS) is software designed to aid clinicians in decision making by matching individual patient characteristics to computerized knowledge bases for the purpose of generating patient-specific assessments or recommendations.
Clinical Guidelines (Protocols): Clinical guidelines are recommendations based on the latest available evidence for the appropriate treatment and care of a patient’s condition.
Clinical messaging: Communication of clinical information within the electronic medical record to other healthcare personnel.
Claim: A request by an individual (or his or her provider) to that individual's insurance company to pay for services obtained from a health care professional.
Claims Review: The method by which an enrollee's health care service claims are reviewed prior to reimbursement. The purpose is to validate the medical necessity of the provided services and to be sure the cost of the service is not excessive.
CMS (formerly HCFA) : The Centers for Medicare & Medicaid Services (CMS), previously known as the Health Care Financing Administration (HCFA), is a federal agency within the United States Department of Health and Human Services (DHHS) that administers the Medicare program and works in partnership with State governments to administer Medicaid, the State Children's Health Insurance Program (SCHIP), and health insurance portability standards.
CMS-1450: The uniform institutional claim form.
CMS-1500: The uniform professional claim form.
COBRA: See Consolidated Omnibus Budget Reconciliation Act.
Coded Data: Data are separated from personal identifiers through use of a code. As long as a link exists, data are considered indirectly identifiable and not anonymous or anonymized. Coded data are not covered by the HIPAA Privacy Rule, but are protected under the Common Rule.
Code Set: Under HIPAA, this is any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes. This includes both the codes and their descriptions.
Coding: A mechanism for identifying and defining physicians' and hospitals' services. Coding provides universal definition and recognition of diagnoses, procedures and level of care. Coders usually work in medical records departments and coding is a function of billing. Medicare fraud investigators look closely at the medical record documentation, which supports codes and looks for consistency. Lack of consistency of documentation can earmark a record as "up-coded" which is considered fraud. A national certification exists for coding professionals and many compliance programs are raising standards of quality for their coding procedures.
Co-Insurance (coinsurance): A cost-sharing requirement under a health insurance policy that provides that the insured will assume a portion or percentage of the costs of covered services. Health care cost which the covered person is responsible for paying, according to a fixed percentage or amount. A policy provision frequently found in major medical insurance policies under which the insured individual and the insurer share hospital and medical expenses according to a specified ratio. A type of cost sharing where the insured party and insurer share payment of the approved charge for covered services in a specified ratio after payment of the deductible. Under Medicare Part B, the beneficiary pays coinsurance of 20 percent of allowed charges. Many HMOs provide 100% insurance (no coinsurance) for preventive care or routing care provided "in network".
Common Rule: Under HIPAA, it outlines the necessity of obtaining informed consent from patients.
Computer-Based Patient Record (CPR): A term for the process of replacing the traditional paper-based chart through automated electronic means; generally includes the collection of patient-specific information from various supplemental treatment systems, i.e., a day program and a personal care provider; its display in graphical format; and its storage for individual and aggregate purposes. CPR is also called “digital medical record” or “electronic medical record”.
Consolidated Omnibus Budget Reconciliation Act (COBRA): Federal law that continues health care benefits for employees whose employment has been terminated. Employers are required to notify employees of these benefit continuation options, and, failure to do so can result in penalties and fines for the employer. It is an act that allows workers and their families to continue their employer-sponsored health insurance for a certain amount of time after terminating employment. COBRA imposes different restrictions on individuals who leave their jobs voluntarily versus involuntarily (Department of Labor, 2002).
Co-Payment, Co-payment, Co-pay: A cost-sharing arrangement in which the HMO enrollee pays a specified flat amount for a specific service (such as $10 for an office visit or $5 for each prescription drug). The amount paid must be nominal to avoid becoming a barrier to care. It does not vary with the cost of the service and is usually a flat sum amount such as $10 for every prescription or doctor visit, unlike co-insurance that is based on a percentage of the cost.
Cost Sharing: Payment method where a person is required to pay some health costs in order to receive medical care. The general set of financing arrangements whereby the consumer must pay out-of-pocket to receive care, either at the time of initiating care, or during the provision of health care services, or both. This includes deductibles, coinsurance and co-payments, but not the share of the premium paid by the person enrolled.
Current Procedural Terminology (CPT): A standardized mechanism of reporting services using numeric codes as established and updated annually by the AMA. It is a manual that assigns five digit codes to medical services and procedures to standardize claims processing and data analysis. The coding system for physicians' services developed by the CPT Editorial Panel of the American Medical Association; basis of the Medicare coding system for physicians services. A medical code set of physician and other services, maintained and copyrighted by the American Medical Association (AMA), and adopted by the Secretary of HHS as the standard for reporting physician and other services on standard transactions. See Coding.
Customary, prevailing, and reasonable (CPR): Current method of paying physicians under Medicare. Payment for a service is limited to the lowest of (1) the physician's billed charge for the service, (2) the physician's customary charge for the service, or (3) the prevailing charge for that service in the community. Similar to the Usual, Customary, and Reasonable system used by private insurers.
[ D ]
Database Management System (DBMS): The separation of data from the computer application that allows entry or editing of data.
Data Content: Under HIPAA, this is all the data elements and code sets inherent to a transaction, and not related to the format of the transaction.
Decision Support System: Computer technologies used in healthcare that allow providers to collect and analyze data in more sophisticated and complex ways. Activities supported include case mix, budgeting, cost accounting, clinical protocols and pathways, outcomes, and actuarial analysis.
Deductibles: Amounts required to be paid by the insured under a health insurance contract, before benefits become payable. This is usually expressed in terms of an "annual" amount.
DICOM (Digital Imaging and Communications in Medicine): Digital Imaging and Communications in Medicine (DICOM) is a standard to aid the distribution and viewing of medical images, such as CT scans, MRIs, and ultrasound.
Disease Management: A type of product or service now being offered by many large pharmaceutical companies to get them into broader healthcare services. Bundles use of prescription drugs with physician and allied professionals, linked to large databases created by the pharmaceutical companies, to treat people with specific diseases. The claim is that this type of service provides higher quality of care at more reasonable price than alternative, presumably more fragmented, care. The development of such products by hugely capitalized companies should be the entire indicator necessary to convince a provider of how the healthcare market is changing. Competition is coming from every direction--other providers of all types, payers, employers who are developing their own in-house service systems, the drug companies.
Document Imaging: Is a process of converting paper documents into an electronic format usually through a scanning process.
Documentation: The process of recording information.
Document Management: The Document Manager allows the medical institution to store vital patient documents such as X-Ray’s, Paper Reports, and Lab Reports etc.
Drug Formulary: Varying lists of prescription drugs approved by a given health plan for distribution to a covered person through specific pharmacies. Health plans often restrict or limit the type and number of medicines allowed for reimbursement by limiting the drug formulary list. The list of prescription drugs for which a particular employer or State Medicaid program will pay. Formularies are either "closed," including only certain drugs or "open," including all drugs. Both types of formularies typically impose a cost scale requiring consumers to pay more for certain brands or types of drugs. See also Formulary.
[ E ]
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 a policy's coverage of a risk goes into effect.
Electronic health records (EHR): is a distributed personal health record in digital format. The EHR provides secure, real-time, patient-centric information to aid clinical decision-making by providing access to a patient's health information at the point of care.
Electronic Claim: A digital representation of a medical bill generated by a provider or by the provider's billing agent for submission using telecommunications to a health insurance payer. Most claims are electronically submitted.
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. This refers to the exchange of routine business transactions from one computer to another in a standard format, using standard communications protocols.
Electronic Medical Records (EMR): A computer-based record containing health care information. This technology, when EMR 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 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.
EPR: Broadly defined, a personal health record is the documentation of any form of patient information–including medical history, medicines, allergies, visit history, or vaccinations–that patients themselves may view, carry, amend, annotate, or maintain. Today, when we refer to PHRs, we typically mean an online personal health record–which may variously be referred to as an ePHR, an Internet PHR, an Internet medical record, or a consumer Internet Medical Record (CIMR). Generally, such records are maintained in a secure and confidential environment, allowing only the individual, or people authorized by the individual, to access the medical information. Not all electronic PHRs are Internet PHRs. PC-based PHRs may be set up to capture medical information offline.
Electronic Super bill: An electronic encounter form used for coding and billing.
EPR (Electronic Patient Record): Electronically maintained information about an individual's lifetime health status and healthcare from all specialties.
Evidence based medicine: Evidence-based medicine (EBM) is the integration of best research evidence with clinical expertise to aid in the diagnosis and management of patients.
[ F ]
Face Sheet: Also called a Summary Screen or Patient Dashboard. This screen includes a summary of patient relevant information on one screen.
Family History: A list of the patient's family medical history including the chronic medical problems of parents, siblings, grandparents, etc.
Fee Schedules: A list of all CPT and HCPCS codes and their corresponding charges. This can be variable based on insurance. Fee schedules are usually associated with a particular payer and reflect the reimbursement rates negotiated under the contract.
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. In HMOs, physicians are often required to prescribe from the formulary. See also Drug Formulary.
[ G ]
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: 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 and Human Services (HHS): The Department of Health and Human Services that is responsible for health-related programs and issues. Formerly it was known as HEW, the Department of Health, Education, and Welfare. The Office of Health Maintenance Organizations (OHMO) is part of HHS and detailed information on most companies is available here through the Freedom of Information Act.
HCFA 1500: The Health Care Finance Administration's standard form for submitting provider service claims to third party companies or insurance carriers. HCFA is now called CMS, see CMS.
HCFA-1450: More commonly known as the UB-92 (Universal Bill). This is also an insurance claim form, but is used for hospital visits and rural health claims. It is characterized by including more procedure level reporting lines, as well as place for information such as hospital days.
Health: The state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. It is recognized, however, that health has many dimensions (anatomical, physiological, and mental) and is largely culturally defined. The relative importance of various disabilities will differ depending upon the cultural milieu and the role of the affected individual in that culture. Most attempts at measurement have been assessed in terms or morbidity and mortality.
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, reprising 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.
Health Care Financing Administration (HCFA): The federal government agency within the Department of Health and Human Services which directs and oversees the Medicare and Medicaid programs (Titles XVIII and XIX of the Social Security Act) and conducts research to support those programs. It is now called CMS and generally it oversees the state's administrations of Medicaid, while directly administering Medicare. See CMS, or Center for Medicare and Medicaid Services.
Health Care Operations: Institutional activities that are necessary to maintain and monitor the operations of the institution. Examples include but are not limited to: conducting quality assessment and improvement activities; developing clinical guidelines; case management; reviewing the competence or qualifications of health care professionals; education and training of students, trainees and practitioners; fraud and abuse programs; business planning and management; and customer service. Under the HIPAA Privacy Rule, these are allowable uses and disclosures of identifiable information "without specific authorization." Research is not considered part of health care operations.
Health Care Provider: Providers of medical or health care or researchers who provide health care are health care providers. Normally health care providers are clinics, hospitals, doctors, dentists, psychologists and similar professionals.
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 Employer Data and Information Set (HEDIS): A set of HMO performance measures that are maintained by the National Committee for Quality Assurance. HEDIS data is collected annually and provides an informational resource for the public on issues of health plan quality.
Health Information: Information in any form (oral, written or otherwise) that relates to the past, present or future physical or mental health of an individual. That information could be created or received by a health care provider, a health plan, a public health authority, an employer, a life insurer, a school, a university or a health care clearinghouse. All health information is protected by state and federal confidentiality laws and by HIPAA privacy rules.
Health Insurance: Financial protection against the health care costs of the insured person. It may be obtained in a group or individual policy.
Health Insurance Portability and Accountability Act of 1996 (HIPAA): A Federal law that allows persons to qualify immediately for comparable health insurance coverage when they change their employment relationships. This legislation sets a precedent for Federal involvement in insurance regulation. It sets minimum standards for regulation of the small group insurance market and for a set group in the individual insurance market in the area of portability and availability of health insurance. As a result of this law, hospitals, doctors and insurance companies are now required to share patient medical records and personal information on a wider basis. This wide-based sharing of medical records has led to privacy rules, greater computerization of records and consumer concerns about confidentiality. In addition, HIPAA required the creation of a federal law to protect personally identifiable health information; if that did not occur by a specific date (which it did not), HIPAA directed the Department of Health and Human Services (DHHS) to issue federal regulations with the same purpose. DHHS has issued HIPAA privacy regulations (the HIPAA Privacy Rule) as well as other regulations under HIPAA. HIPAA gives HHS the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care information. This is also known as the Kennedy-Kassebaum Bill, the Kassebaum-Kennedy Bill, K2, or Public Law 104-191.
Health Level Seven (HL7): A data interchange protocol for health care computer applications that simplifies the ability of different vendor-supplied IS systems to interconnect. Although not a software program in itself, HL7 requires that each healthcare software vendor program HL7 interfaces for its products.
Health Maintenance Organization (HMO): HMOs offer prepaid, comprehensive health coverage for both hospital and physician services. The HMO is paid monthly premiums or capitated rates by the payers, which include employers, insurance companies, government agencies, and other groups representing covered lives. The HMO must meet the specifications of the federal HMO act as well as meeting many rules and regulations required at the state level. There are 4 basic models: group model, individual practice association, network model and staff model. An HMO contracts with health care providers, e.g., physicians, hospitals, and other health professionals. The members of an HMO are required to use participating or approved providers for all health services and generally all services will need to meet further approval by the HMO through its utilization program. Members are enrolled for a specified period of time. HMOs may turn around and sub-capitate to other groups. For example, it may carve-out certain benefit categories, such as mental health, and sub-capitate these to a mental health HMO. Or the HMO may sub-capitate to a provider, provider group or provider network. HMOs are the most restrictive form of managed care benefit plans because they restrict the procedures, providers and benefits.
Help Desk: Service and support desk
History of Present Illness (HPI): The HPI is the history of the patient’s chief complaint.
Human Subject: Under HIPAA rules, this term refers to a living subject participating in research about whom directly or indirectly identifiable health information or data are obtained or created.
[ I ]
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.
Informatics: The application of computer technology to the management of information.
Integration: Integration allows for secure communication between enterprise applications.
Interoperability: The capability to provide successful communication between end-users across a mixed environment of different domains, networks, facilities and equipment.
Insurance Eligibility Check: to take care of the vital process of checking patient’s insurance eligibility often results in billing errors, insurance coverage concerns and delays.
Immunization: A complete list of all immunizations that the patient has had.
ISP: Internet Service Provider
IT (Information Technology): The development, installation, and implementation of computer systems and applications.
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.
Interface: A means of communication between two computer systems, two software applications or two modules. Real time interface is a key element in healthcare information systems due to the need to access patient care information and financial information instantaneously and comprehensively. Such real time communication is the key to managing health care in a cost effective manner because it provides the necessary decision-making information for clinicians, providers and payers.
Internal Medicine: Generally, that branch of medicine that is concerned with diseases that do not require surgery, specifically, the study and treatment of internal organs and body systems; it encompasses many subspecialties; internists, the doctors who practice Internal medicine, often serve as family physicians to supervise general medical care.
[ 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 usually surveys organizations once every 3 years, 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.
[ L ]
LAN (Local Area Network): A LAN supplies networking capability to a group of computers in close proximity to each other such as in an office building, a school, or a home.
Legacy Systems: Computer applications, both hardware and software, which have been inherited through previous acquisition and installation. Most often, these systems run business applications that are not integrated with each other. Newer systems which stress open design and distributed processing capacity are gradually replacing such systems.
Legacy System Integration: The integration of data between a legacy system and some other software program most commonly using HL-7 standards.
LEPR (Longitudinal Patient Record): Longitudinal Patient Record is an EHR that includes all healthcare information from all sources.
Legend Drug: Drug that the law says can only be obtained by prescription.
Length of Stay (LOS): The duration of an episode of care for a covered person. The number of days an individual stays in a hospital or inpatient facility. May also be reviewed as Average Length of Stay (ALOS).
Licensing: A process most States employ, which involves the review and approval of applications from HMOs prior to beginning operation in certain areas of the State. Areas examined by the licensing authority include: fiscal soundness, network capacity, MIS, and quality assurance. The applicant must demonstrate it can meet all existing statutory and regulatory requirements prior to beginning operations.
Lifetime Limit: A cap on the benefits paid under a policy. Many policies have a lifetime limit of $1 million, which means that the insurer agrees to cover up to $1 million in covered services over the life of the policy.
[ M ]
M.A. (Medical Assistant): If certified, is referred to as CMA. Some clinics have similar positions known as Clinical Assistants. Used in most offices as a part of the nursing staff with responsibilities including working up patients, triaging and returning patient calls and assisting the provider in general.
MD: Medical Doctor
Management Information System (MIS): The common term for the computer hardware and software that provides the support of managing the plan.
Master Patient / Member Index: An index or file with a unique identifier for each patient or member that serves as a key to a patient's or member's health record.
Maximum Allowable Actual Charge (MAAC): A limitation on billed charges for Medicare services provided by nonparticipating physicians. For physicians with charges exceeding 115 percent of the prevailing charge for nonparticipating physicians, MAACs limit increases in actual charges to 1 percent a year. For physicians whose charges are less than 115 percent of the prevailing, MAACs limit actual charge increases so they may not exceed 115 percent.
Maximum Defined Data Set: Under HIPAA, this is all of the required data elements for a particular standard based on a specific implementation specification. An entity creating a transaction is free to include whatever data any receiver might want or need. The recipient is free to ignore any portion of the data that is not needed to conduct their part of the associated business transaction, unless the inessential data is needed for coordination of benefits.
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.
Medical Transcription: A PDA-compliant medical transcription system that manages the transcription cycle from the beginning to end by integrating voice recording, digital scripting, delivery of voice files to the medical transcriptionist and final transcript receipt.
Medical Calculators: A diverse range of Medical Calculators that allows the medical practitioner to make rapid, accurate calculations within seconds, with the focus on “evidence based medicine”.
Medication Reviewer: is a complete list of all medications that the patient is on or had been taking at some point.
Medical Group Practice: The American Group Practice Association, the American Medical Association, and the Medical Group Management Association define medical group practice as: provision of health care services by a group of at least three licensed physicians engaged in a formally organized and legally recognized entity sharing equipment, facilities, common records and personnel involved in both patient care and business management.
Medical Informatics: Medical informatics is the systematic study, or science, of the identification, collection, storage, communication, retrieval, and analysis of data about medical care services to improve decisions made by physicians and managers of health care organizations. Medical informatics will be as important to physicians and medical managers as the rules of financial accounting are to auditors.
Medical Management Information System (MMIS): A data system that allows payers and purchasers to track health care expenditure and utilization patterns. It may also be referred to as Health Information System (HIS), Health Information Management (HIM) or Information System (IS). See also Electronic Medical Record (EMR).
Mid-level Practitioner: Refers to the group of providers considered to be one-level below M.D.s and D.O.s. Physician assistants (P.A.s) and Nurse Practitioners (N.P.s) are examples.
Modifier: A two-character code added to a CPT or HCPCS code that is used to help in the reimbursement process. For example, a modifier can be used to explain that a procedure not normally covered when billed on the same day as another is actually a separate and significant process, or that it is a rural health procedure that gets higher reimbursement. Up to 4 modifiers can be attached to each CPT, although in most cases only 1 or 2 are used.
Multi-Specialty Group: A group of doctors who represent various medical specialties and who work together in a group practice.
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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. The classification system for drug identification is similar to UPC code.
Neonatal Intensive Care Unit (Neo ICU): A hospital unit with special equipment for the care of premature and seriously ill newborn infants.
Non-Participating Physician (or Provider): A provider, doctor or hospital that does not sign a contract to participate in a health plan, usually which requires reduced rates from the provider. In the Medicare Program, this refers to providers who are therefore not obligated to accept assignment on all Medicare claims. In commercial plans, non-participating providers are also called out of network providers or out of plan providers. If a beneficiary receives service from an out of network provider, the health plan (other than Medicare) will pay for the service at a reduced rate or will not pay at all.
Non-Plan Provider: A health care provider without a contract with an insurer. A non plan Provider is also known as nonparticipating provider.
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. Nurse Practitioners are sometimes considered "midlevel practitioners".
NPI (National Provider Identifier): Fairly new 8 digit alphanumeric identifier given to all medical facilities. Most M.D.s and DOS do not have NPIs at this time (they still use UPIN numbers). However, mid-level practitioners usually do. NSF (National Standard Format): Standard format for electronic filing.
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Occupancy Rate: A measure of inpatient health facility use, determined by dividing available bed days by patient days. It measures the average percentage of a hospital's beds occupied and may be institution-wide or specific for one department or service.
Ombudsperson or Ombudsman: A person within a managed care organization or a person outside of the health care system (such as an appointee of the state) who is designated to receive and investigate complaints from beneficiaries about quality of care, inability to access care, discrimination, and other problems that beneficiaries may experience with their managed care organization. This individual often functions as the beneficiary's advocate in pursuing grievances or complaints about denials of care or inappropriate care. Organizations are mostly able to designate a member of their own staff as ombudsman.
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.
Open Panel: 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 Access.
Outcome: A clinical outcome is the result of medical or surgical intervention or nonintervention, or the results of a specific health care service or benefit package. The valued results of care as experienced primarily by the patient but also by physicians and all other participants in the processes contributing to the outcomes.
Outcomes Management: Providers and payers alike wish to find a method of managing care in a way that would produce the best outcomes. Managed care organizations are increasingly interested in learning to manage the outcome of care rather than just managing the cost of care. It is thought that through a database of outcomes experience, caregivers will know better which treatment modalities result in consistently better outcomes for patients. Outcomes management may lead to the development of clinical protocols. A clinical outcome is the result of medical or surgical intervention or nonintervention. Managed services organizations are now attempting to better manage clinical outcomes for their enrollees to increase the satisfaction of patients and payers while holding down costs.
Outcomes Measurement: System used to systematically track clinical treatment and responses to that treatment. The methods for measuring outcomes are quite varied among providers. Much disagreement exists regarding the best practice or tools to utilize to measure outcomes. In fact, much disagreement exists in the medical field about the definition of outcome itself. A tool to assess the impact of health services in terms of improved quality and/or longevity of life and functioning.
Outcomes Research: Research on measures of changes in patient outcomes, that is, patient health status and satisfaction, resulting from specific medical and health interventions. Attributing changes in outcomes to medical care requires distinguishing the effects of care from the effects of the many other factors that influence patients' health and satisfaction. With the elimination of the physician's fiduciary responsibility to the patient, outcomes data is gaining increasing importance for patient advocacy and consumer protection. Outcomes research will also be used in the future by payers to identify potential partners on the basis of good outcomes.
Outpatient Care: Care given a person who is not bedridden. It is 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.
Office Visit Levels:Otherwise know as E&M codes, the code varies from Level I to V depending on complexity with V being the most complex.
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Past Medical History, Past Surgical History, Screening (PMSS): This is a list of all the past surgery and medical issues that the patient has been treated for.
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.
P.A. (Physician Assistant): A mid-level provider. They are required to have a Bachelor's degree and then attend a rigorous 3-year training program mainly instructed by physicians. They are not physicians, but in most states have similar rights and privileges. However, they must be supervised by a physician.
Past Medical History: A list of a patient's past health problems, surgeries and specialists.
Patient Demographics: All the patient's pertinent information such as first and last name, SSN, DOB, insurance, etc.
Patient Origin Study: A study, generally undertaken by an individual health program or health planning agency, to determine the geographic distribution of the residences of the patients served by one or more health programs. Such studies help define catchment and medical trade areas and are useful in locating and planning the development of new services.
Participating Physician: A primary care physician in practice in the payer's managed care service area who has entered into a contract.
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. Part B, on the other hand, refers to outpatient coverage.
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.
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.
Payer (usually Third Party Payer): The public or private organization that is responsible for payment for health care expenses. Payers may be insurance companies or self-insured employers.
PC Based: A program designed to run on an individual PC. This typically means data is not shared in real time among other PCs (users).
PCP: Primary care physician who often acts as the primary gatekeeper in health plans. That is, often the PCP must approval referrals to specialists. Particularly in HMOs and some PPOs, all members must choose or are assigned a PCP.
PHR: A personal health record or PHR is typically a health record that is initiated and maintained by an individual. An ideal PHR would provide a complete and accurate summary of the health and medical history of an individual by gathering data from many sources and making this information accessible online.
Physician Attestation: The requirement that the attending physician certify, in writing, the accuracy and completion of the clinical information used for DRG assignment.
Physician Current Procedural Terminology (CPT): List of services and procedures performed by providers, with each service/procedure having a unique 5-digit identifying code. CPT is the health care industry's standard for reporting of physician services and procedures. Used in billing and records.
Progress Note: The documentation of a patient visit or encounter including all or part of the SOAP format.
Practical Nurses: Practical nurses, also known as vocational nurses, provide nursing care and treatment of patients under the supervision of a licensed physician or registered nurse. Licensure as a licensed practical nurse (L.P.N.) or in California and Texas as a licensed vocational nurse (L.V.N.) is required.
Practice Parameters, Practice Guidelines: Systematically developed statements to standardize care and to assist in practitioner and patient decisions about the appropriate health care for specific circumstances. Practice guidelines are usually developed through a process that combines scientific evidence of effectiveness with expert opinion. Practice guidelines are also referred to as clinical criteria, protocols, algorithms, review criteria, and guidelines. The American Medical Association defines practice parameters as strategies for patient management, developed to assist physicians in clinical decision-making. Practice parameters may also be referred to as practice options, practice guidelines, practice policies, or practice standards.
Pre-Authorization: A cost containment feature of many group medical policies whereby the insured must contact the insurer prior to a hospitalization or surgery and receive authorization for
Primary Care: Basic or general health care usually rendered by general practitioners, family practitioners, internists, obstetricians and pediatricians who are often referred to as primary care practitioners or PCPs. Professional and related services administered by an internist, family practitioner, obstetrician-gynecologist or pediatrician in an ambulatory setting, with referral to secondary care specialists, as necessary.
Primary Care Network (PCN): A group of primary care physicians who share the risk of providing care to members of a given health plan.
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. Also see Primary Care Provider.
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. See also Gatekeeper.
Principal Diagnosis: The medical condition that is ultimately determined to have caused a patient's admission to the hospital. The principal diagnosis is used to assign every patient to a diagnosis related group. This diagnosis may differ from the admitting and major diagnoses.
Prior Authorization: A formal process requiring a provider obtain approval to provide particular services or procedures before they are done. This is usually required for nonemergency services that are expensive or likely to be abused or overused. A managed care organization will identify those services and procedures that require prior authorization, without which the provider may not be compensated.
Privacy: For purposes of the HIPAA Privacy Rule, privacy means an individual's interest in limiting who has access to personal health care information. See also HIPAA Privacy Rule. Psychotherapy Notes: These include notes recorded by the health care provider who is a mental health professional during a counseling session, either in a private session or in a group. These notes are separate from documentation placed in the medical chart and do not include prescriptions. Specific patient authorization is required for use and disclosure of psychotherapy notes.
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Real Time: The instantaneous sharing of data among a user group. It is common to a client/server database configuration.
Referral: Some insurance companies require that on specific plans a referral must be obtained for certain procedures or visits to specialists. The referral is acquired by the primary care physician (PCP) by contacting the insurance company by phone or mail. This is a request for the service. The referral consists of an authorization code, a number of visits allowed (if applicable) and an expiration date.
Referring Provider: is the provider that referred the patient to a specialist or for a specific procedure.
Relational Database: A database program that stores data in a manner similar to Excel, with the difference being the data elements are related (linked) to each other.
Rendering/Performing Provider: The provider actually treating the patient.
Registered Nurses (R.N.'s): 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.
ROS (Review of Systems): A series of questions related to the system(s) that the patient is having complaints about (i.e. respiratory for cold symptoms).
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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.
SOAP Note: Progress note format utilized by Medinformatix that consists of Subjective, Objective, Assessment and Plan sections.
Social History: A description of a patient's social habits and history including marital status, alcohol and drug use and exercise habits.
Subjective: Section in a progress note where a patient's account of their current problem is documented. Consists of chief complaint, HPI and ROS.
Superbill: Also known as an encounter form, route slip or fee slip. This is a paper charge capture tool used to document coding for a specific patient visit. It is a printed form with patient information at the top, and a subset of the provider's/practice's most commonly used ICD and/or CPT codes. The form travels with the patient through the clinic. Providers check off items when they see the patient, and the form then travels to the checkout desk or billing office where the codes are entered into the billing system.
Supervising Provider: The physician that is supervising patient care for a mid-level. In some practices, the supervising provider signs off on every chart after a mid-level sees a patient, while in others he is simply available to assist if necessary. Physicians in some rural areas do not have to be on-site and can supervise remotely.
SQL: Sequential Query Language – The most common database language in the world. There are several varieties of SQL on the market. The most popular is Microsoft SQL.
Sx: Abbreviation for symptoms
Skilled Nursing Facility (SNF): A licensed institution, as defined by Medicare, which is primarily engaged in the provision of skilled nursing care. SNFs are usually DRG or PPS exempt and are located within hospitals, but sometimes are located in rehab facilities or nursing homes.
Solo Practice, Solo Practitioner: A physician who practices alone or with others but does not pool income or expenses. This form of practice is becoming increasingly less common as physicians band together for contracting, overhead costs and risk sharing.
Subscriber:- Person responsible for payment of premiums, or person whose employment is the basis for membership in a health plan.
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Trial Balance: A detailed report of invoices for a patient.
Therapeutic Alternatives:strong Drug products that provide the same pharmacological or chemical effect in equivalent doses. Also see Drug Formulary.
Treatment: The provision of health care by one or more health care providers. Treatment includes any consultation, referral or other exchanges of information to manage a patient's care. The HIPAA Privacy Notice explains that the HIPAA Privacy Rule allows Partners and its affiliates to use and disclose protected health information for treatment purposes without specific authorization.
Treatment Episode: The period of treatment between admission and discharge from a modality, e.g., inpatient, residential, partial hospitalization, and outpatient, or the period of time between the first procedure and last procedure on an outpatient basis for a given diagnosis. Many healthcare statistics and profiles use this unit as a base for comparisons.
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UB-92 - Uniform Billing Code of 1992: Bill form used to submit hospital insurance claims for payment by third parties. Similar to 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.
UPIN: A standard 6 digit alphanumeric identifier assigned to providers. Can be used for single provider or a group/facility.
URI: Abbreviation for Upper Respiratory Infection (Cold)
UTI: Abbreviation for Urinary Tract Infection (Bladder infection)
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VPN: Virtual Private Network – A VPN “tunnel” is a secure connection, typically firewall to firewall that provides for remote access to your data server.
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. See also Fixed Contribution Health Plan.
Vital Statistics
- Statistics relating to births (natality), deaths (mortality), marriages, health, and disease (morbidity). Vital statistics for the United States are published by the National Center for Health Statistics. Vital statistics can be obtained from CDC, state health departments, county health departments and other agencies. An individual patient's vital statistics in a health care setting may also refer simply to blood pressure, temperature, height and weight, etc.
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Wave Scheduling: Scheduling patients in "waves", i.e. scheduling several patients at the top of the hour (in the same time slot), and several at the bottom of the hour. Patients rarely arrive on time, and offices often run behind. Having blocks of busy and catch-up time can even this out. Modified wave scheduling is a more recent trend where the schedule is based around the actual time spent with patients. Most patient visits do not require the provider to be in the room with the patient for 100% of the time. Wave scheduling allows more efficient scheduling by allowing for this. For example, a patient visiting an ophthalmologist may spend 15 minutes of a half hour visit waiting for their eyes to dilate. The doctor is only present for the last 15 minutes. Thus, another patient could be scheduled for the first 15 minutes. Thus, modified wave scheduling refers to creating a schedule that accounts only for the providers' time spent with patients. This is only efficient if there is enough nursing staff to prepare several patients simultaneously.
Waiting Periods: The length of time an individual must wait to become eligible for benefits for a specific condition after overall coverage has begun.
Waiver : Approval that the Centers for Medicare and Medicaid Services (CMS, formerly called HCFA), the federal agency that administers the Medicaid program, may grant to state Medicaid programs to exempt them from specific aspects of Title XIX, the federal Medicaid law. Most federal waivers involve loss of freedom of choice regarding which providers beneficiaries may use, exemption from requirements that all Medicaid programs be operated throughout an entire state, or exemption from requirements that any benefit must be available to all classes of beneficiaries (which enables states to experiment with programs only available to special populations).
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. See Authorization also.
Workers' Compensation: 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. See also Occupational Health. |
