Term
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Definition
| ADJUSTED ANNUAL PER CAPITA COST |
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Definition
| term used by cms for the process of adding new medicare enrolles to a plan. |
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Definition
| the amount of money that is se asside to cover expenses |
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| adjusted community rate used in the past by medicare managed care plans. |
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Definition
| ambulatory diagonstic group |
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Definition
| The management and processing of claims by an MCO or Health insurance company. |
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Definition
| the problem of attracting members who are sicker than the general population. |
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| Americans Health Insurance Plans. The primary trade organization of managed care org. |
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Definition
| The maximum charge that an MCO or other payer will pay for a specific service. |
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Definition
| Health care services that are ordered by a physician, but provided by some other type of provider. |
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Definition
| The maximum amount of coverage that a health plan will provide in a year. |
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| The Americans National Standards Institute. ANSI develops and maintains standards for electronic data interchange. |
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Definition
| Ambulatory patient classification. |
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Definition
| Ambulatory Patient Group. A reimbursement methodology developed by 3M. |
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Definition
| Administraive services only. |
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Definition
| The payment of medical benefits directily to a provider of care rather than a member. |
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| An association made up of smaller businesses that group together for purposes of providing health benefits to employees. |
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Definition
| in context of managed care, refers to the need to obtain authorization before certain types of health care services are covered. |
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Definition
| the practice of a provider billing a patient for all charges not paid by the insurance plan. |
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Definition
| Balaned Budget Act of 1997 |
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Definition
| Bed days per thousand members |
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Definition
| Complimentary and alternative medicine |
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Definition
| A set amount of money received or paid out. It is based membership rather than services delievered. |
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Term
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Definition
| set of medical services that are carved out of the basic arrangement. |
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Definition
| A method of managin the provision of health care to members |
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Term
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Definition
| consumer-directed health plan |
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Definition
| the license required by an HMO that is issued by the state. |
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Definition
| The list of charges a hospital has for each and everything it can charge for on a pure FFS basis. |
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Definition
| the practice of a provider seeing a patient more often than is medically necessary. |
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Definition
| the term used to describe a bill for services |
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Definition
| a company that accepts claims or other transactions from providers, formats them into HIPPA-compliant standards and electronically transmits them to the payer. |
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Definition
| a managed care plan that contracts with physicians on an exclusive basis. |
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Definition
| the centers for Medicare and Medicaid services. |
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Definition
| A paper claim form used by hospitals and facilities, standardized by CMS. |
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Term
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Definition
| A paper claims form used by professionals to bill for services |
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Term
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Definition
| Certificate of authority. State issued operating license for HMO. |
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Definition
| Consolidated Omnibus Reconciliation Act. A portion of this act requires employers to offer the opportunity for terminated employees to purchase continuation of health care coverage. |
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Term
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Definition
| A provision in a members coverage that limits the amount of coverage by the plan. |
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Definition
| The rating methodology required of HMO's under the laws of many States. |
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Definition
| The 12-month period that a contract for services is in force. |
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Definition
| that portion of a claim or medical expense that a member must pay out of pocket. |
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Term
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Definition
| when a provider cannot cover the cost of providing services under the reimbursement received. the provider raises the prices to other payors to cover that portion of the cost. |
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Definition
| obtaining and reviewing the documentation of professional providers. |
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Term
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Definition
| Customer Service Representative |
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Term
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Definition
| Date that medical services were rendered. |
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Definition
| An insurance term that refers to a vicious spiral of high premium rates and adverse selection |
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Term
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Definition
| That portion of a subscribers health care expenses that must be paid out of pocket before any insurance coverage applies. commonly 100-300 dollars. |
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Definition
| Term used by CMS for the process of removing Medicare enrollees from a plan. |
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Term
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Definition
| Services or support that an MCO provides members to lower the demand for acute care services. |
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Term
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Definition
| a member who is covered by virtue of a family relationship with the member who has the health plan coverage. |
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Term
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Definition
| Department of Health and Human Services |
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Term
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Definition
| managed care health plan that contracts directly with private practice physicians. |
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Term
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Definition
| That part of utilization management that is concerned with arranging for care or medical needs to facilitate discharge from hospital. |
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Term
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Definition
| the process of termination of coverage. |
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Term
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Definition
| Durable medical equipment |
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Term
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Definition
| The Term applied to the difference between when first-dollar coverage stops and insurance begins. |
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Term
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Definition
| A peculiar type of health insurance that only covers a specific and frightening type of illness such as cancer. |
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Definition
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Term
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Definition
| individuals who are entitled to both medicare and medicaid coverage. |
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Term
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Definition
| when the same claim is submitted more than once. |
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Term
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Definition
| the day the health plan coverage goes into effect or is modified. |
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Term
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Definition
| Electronic Funds Transfer |
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Term
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Definition
| when an individual is eligible for coverage under a plan. |
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Term
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Definition
| The Emergency Medical Treatment and Active Labor Act. Legislation dictates that all patients presenting to any hospital emergency department must have a medical screening exam performed by qualified personnel. |
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Term
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Definition
| an outpatient or ambulatory visitby a member to a provider. |
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Definition
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Term
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Definition
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Term
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Definition
| when a physician uses electronic means to presribe drugs. |
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Term
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Definition
| Employee Retirement Income Security Act |
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Term
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Definition
| electronic visit referring to an interaction between a provider and a patient, using a secure electronic communications |
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Term
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Definition
| As used in managed care and health insurance, exclusions refer to those services or conditions for which there will be no coverage. |
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Term
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Definition
| the method of setting premium rates based on the actual health care cost of a group or groups |
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Term
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Definition
| the methodofsetting premium rates based on the actual health care cost of a group or groups. |
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Term
| Extracontractual benefits |
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Definition
| health care benefits beyond what the members actual policy covers. |
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Term
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Definition
| May also be referred to as a fee maximus or as a fee allowable schedule. A listing of the maximum fee that a health plan will pay for a certain service based on CPT billing codes |
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Term
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Definition
| Federal Employee Heatlh Benefits Acquisition Regulations |
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Term
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Definition
| Federal Employee Health Benefits Program |
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Definition
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Term
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Definition
| a company that processes the administrative transactions on behalf of medicare |
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Term
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Definition
| a benefit plan at a company that allows an employee to select from different options up to a set amount of money and always includes an FSA |
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Term
| Flexible spending account |
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Definition
| financial account funded with pre-tax dollars via payroll deduction by an employer |
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Definition
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Definition
| an informal though widely usedterm that refers to a primary care case management model healtplan. |
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Term
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Definition
| Is a financial account of pre-tax dollars for current or future qualified medical expenses retirement, or long term care premium expenses. |
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Term
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Definition
| Health Plan Employer Data Information set. |
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Term
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Definition
| Health Insurance Portability and Accountability Act Enacted 1997 |
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Term
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Definition
| Health Maintenance Organization |
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Term
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Definition
| a contractual clause between a provider and a MCO that prohibits the providerfrom balance billing a member even in the event the MCO fails to pay the provider. |
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Term
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Definition
| a physician who concentrates solely on hospitalized patients |
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Term
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Definition
| incurred but not reported |
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Term
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Definition
| international classification of disease 9th revision, clinical modification |
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Term
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Definition
| loosely defined term that refers to using data mining to creat usable reports |
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Term
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Definition
| Bringing Back into the MCO a process or activity that was once outsourced |
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Term
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Definition
| a type of hospitalist who focuses solely on care provided in the intensive care unit |
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Term
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Definition
| Joint Commission for the Accredidation of Healthcare Organization |
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Term
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Definition
| a report that tells managers how old the claims are that are being processed and how much is paid out each month |
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Term
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Definition
| tool used by finance to manage the lag study |
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Term
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Definition
| Lenght of study/estimated length of stay/average length of stay |
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Term
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Definition
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Term
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Definition
| Benefits that a health plan is required to provide by law |
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Term
| Maximum out of pocket cost |
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Definition
| the most amount of money a member will ever need to pay for covered service during a contract year |
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Term
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Definition
| the ratio between the cost to deliver medical care and the amount of money that wastaken in by a plan |
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Term
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Definition
| the old name for medicare private insurance options, created under BBA 97 |
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Term
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Definition
| a formofstate-licensed health insurance that covers whatever medicare doesnt |
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Term
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Definition
| an individual covered under a managed care plan |
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Term
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Definition
| a managed care planthat mixes two or more types of delivery systems. |
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Term
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Definition
| old term of insurance that remains applicable today. Loosely defined for purposes of this glossary, moral hazard refers to the concept of providing insurance to a market in which it is certain that financial losses will occur. |
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Definition
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Term
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Definition
| management service organizaion |
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Term
| National Practitioner Data Bank |
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Definition
| a data bank established under the federal health care improvement and Quality Act of 1986, it electronically stores information about physician malpractice suits successfully litigated or settled and disciplinary actions upon physicians |
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Term
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Definition
| National Committee on Quality Assurance |
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Term
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Definition
| Short for nonpracticing. Refers to a provider that does not have a contact with the health plan |
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Term
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Definition
| National Provider Indentifier |
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Term
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Definition
| the period when an employee may change health plans. |
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Term
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Definition
| having a process or activity that an MCO provides done by a contracted third party |
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Term
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Definition
| the drug benefit created under the MMA |
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Definition
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Definition
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Term
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Definition
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Term
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Definition
| Reimbursement of an institution usually a hospital basedon set rate per day |
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Definition
| Protected Health Information |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| the money paid to a health plan for coverage |
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Term
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Definition
| Tax levied by a state on health insurance premiums for policies sold in that state |
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Term
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Definition
| Measuring a providers performacne on selected measures and comparing that performance to similar providers |
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Term
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Definition
| the generic term used to refer to anyone providing medical services |
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Term
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Definition
| quality improvement program |
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Term
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Definition
| resource-based relative value scale |
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Term
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Definition
| insurance purchased by a health plan to protect it against extremely high cost cases. |
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Term
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Definition
| a small clinic, usually associated with retail store such as a pharmacy or grocery store. staffed by non-physician providers |
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Term
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Definition
| management activities aimed at lowering an organiztions legaland financial exposueres, especially to lawsuits |
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Term
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Definition
| State children's Health Insurance Program |
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Term
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Definition
| that section of federal law that provides for a state to opt out of the standard medicaid fee-for-service program |
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Term
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Definition
| the practice of setting premium rates at a level just below the competitions rates. |
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Term
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Definition
| social health maintenance organization. An HMO that goes beyond the medical care needs of its membership to include their social needs as well |
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Term
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Definition
| also referred toass a catastrophic claim. A shock claim is an extraordinarily expensive total cost of health care for and individual patient |
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Term
| Single Specialty Hospital |
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Definition
| a hospital that provides services focusing on a single specialty |
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Term
| Specialty pharmacy distributor (SPD) |
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Definition
| a company that distributes specialty pharmacy, from the manufacturer to the provider and/or directly to the patient. |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| the day the health plan coverage is no longer in effect |
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Term
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Definition
| Third-party administrator |
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Term
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Definition
| Refers to making data available to the public |
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Term
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Definition
| the department of Defense's worldwide managed health care program |
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Term
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Definition
| Usual,Customary, or reasonable |
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Term
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Definition
| the practice of a provider billing for a procedure that pays better than the service actually performed. |
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Term
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Definition
| Universal Provider Identification Number. The UPN is being replaced by the NPI |
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Term
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Definition
| commonly used to refer to insurance or health plan coverage for copays and deductibles that are not covered under a member's base plan |
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