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

admitting physician. The doctor responsible for admitting a patient to a hospital or other inpatient health facility.

ancillary services. Auxiliary or supplemental services, such as diagnostic services, home health services, physical therapy, and occupational therapy used to support diagnosis and treatment of a condition.

appeal. A special kind of complaint you make if you disagree with a decision to deny a request for healthcare services or payment for services you already received. You may also make a complaint if you disagree with a decision to stop services that you are receiving.

B

behavioral healthcare. The provision of mental health and chemical dependency (substance abuse) services.

best practices. Actual practices, in use by qualified providers following the latest treatment protocals, that produce the best measurable results.

board certified. This means a doctor has special training in a certain area of medicine and has passed an advanced exam in that area of medicine. Both primary care doctors and specialists may be board-certified.

capitation. A fixed per capita payment made periodically to a medical service provider (as a physician) by a managed care group (as an HMO) in return for medical care provided to enrolled individuals.

case management. A process of identifying plan members with special healthcare needs, developing a healthcare strategy to meet those needs, and coordinating and monitoring care. A process used by a doctor, nurse, or other health professional to manage your health care. Case managers make sure that you get needed services, and track your use of facilities and resources.

certified nursing assistant (CNA). CNAs are trained and certified to help nurses by providing non-medical assistance to patients, such as help with bathing, dressing, and using the bathroom.

chronic. A condition that persists for long periods of time or marked by frequent recurrence.

claim. An itemized statement of healthcare services and the costs associated with the services. Claims are submitted by a hospital, physician office, or other provider facility to the insurer or managed care plan for payment of the costs incurred.

claimant. The person or entity submitting a claim.

claims processor. Employees in the claims department who consider all the information pertinent to a claim and make decisions about the payment of the claim. Also known as claims analyst or claims examiner.

claims supervisor. An employee who supervises and oversees the work of multiple claims processors.

clinical breast exam. An exam by your doctor or healthcare provider to check for breast cancer by feeling and looking at your breasts. The exam is different from a mammogram and is usually done in the doctor's office during your Pap test and pelvic exam.

clinical practice guidelines. Reports written by experts who have carefully studied whether a treatment works and which patients are most likely to be helped by it.

clinical trials. One of the final stages of a long and careful research process to help patients live longer, healthier lives. They help doctors and researchers find better ways to prevent, diagnose, or treat diseases. Clinical trials test new types of medical care and help doctors and researchers determine if the new care works and if it is safe. They may also be used to compare different treatments for the same condition to see which treatment is better, or to test new uses for treatments already in use.

COBRA. See Consolidated Omnibus Budget Reconciliation Act.

concurrent review. A type of utilization review that occurs while treatment is in progress and typically applies to services, such as inpatient stays, that continue over a period of time.

Consolidated Omnibus Budget Reconciliation Act (COBRA). A federal act which requires each group health plan to allow employees and certain dependents to continue their group healthcare coverage for a stated period of time following a qualifying event that causes the loss of group health coverage. Qualifying events include reduced work hours, death or divorce of a covered employee, and termination of employment.

coordination of benefits. Process for determining the respective responsibilities of two or more health plans that have some financial responsibility for a medical claim.

copayment. A specified dollar amount that a member must pay out-of-pocket at the time a service is rendered.

covered benefit. A health service or item that is included in your health plan, and that is paid for either partially or fully.

credentialing. The review and verification process used to determine the current clinical competence of a provider and whether the provider meets the preestablished criteria for participation in the network.

custodial care. Non-skilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom.

deductible. A flat amount a group member must pay before the insurance plan will make any benefit payments.

diagnosis. The act or process of identifying or determining the nature and cause of a disease, injury, or medical condition through evaluation of patient history, examination, and review of laboratory data.

discharge planning. A process used to help determine what activities must occur before the patient is ready for discharge and the most efficient way to conduct those activities.

durable medical equipment (DME). Medical equipment that is ordered by a doctor for use in the home. DME items are reusable, such as walkers, wheelchairs, or hospital beds.

electronic data interchange (EDI). The computer-to-computer transfer of data between organizations using a data format agreed upon by the sending and receiving parties.

emergency care. Medical care given for a medical emergency when you believe that your health is in serious danger and every second counts.

ethics. The principles and values that guide the actions of an individual or group when faced with questions of right and wrong.

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

fee schedule. A complete listing of fees determined by an MCO to be acceptable for a procedure or service, which the physician agrees to accept as payment in full.

formulary. A listing of prescribed medications, classified by therapeutic category or disease class, that have been selected by doctors, pharmacists, and other healthcare professionals on the basis of their effectiveness and cost and that are to be used by an MCO's providers in prescribing medications.

generic substitution. A drug that is the generic equivalent of a drug listed on the formulary. Generic substitutions are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. Generic equivalents contain the same active ingredients as their name-brand counterparts and, in most cases, generic substitution can be performed without physician approval and reduce costs for the patient Also known as generic drug.

group health plan. A health plan that provides health coverage to employees, former employees, and their families, and is supported by an employer or employee organization.

health care provider. A person who is trained and licensed to give health care or a place that is licensed to give health care. Doctors, nurses, and hospitals are examples of health care providers.

Health Insurance Portability and Accountability Act (HIPAA). A federal law that outlines the requirements that employer-sponsored group insurance plans, insurance companies, and managed care organizations must satisfy in order to provide health insurance coverage in the individual and group healthcare markets. The HIPAA legislation has four primary objectives:

1. Assure health insurance portability by enabling workers of all professions to change jobs, even if they (or a family member) have a pre-existing medical condition

2. Reduce, detect and prosecute healthcare fraud and abuse

3. Enforce standards for health information

4. Guarantee security and privacy of health information

health maintenance organization (HMO). An organization that provides comprehensive health care for you and your family, including doctors’ visits, hospital stays, emergency care, surgery, lab test, x-rays, and therapy. Upon enrollment, you may choose a doctor to serve as your primary care doctor. This doctor monitors your health and refers you to specialists and other healthcare professionals as needed. Generally, most healthcare is provided either directly by the primary care doctor, by others within the same group practice, or through doctors, specialists, or other healthcare professionals under contract.

home health agency. An organization that gives home care services, like skilled nursing care, physical therapy, occupational therapy, speech therapy, and personal care by home health aides.

home health care. Limited part-time or intermittent skilled nursing care and home health aide services, physical therapy, occupational therapy, speech-language therapy, medical social services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), medical supplies, and other services.

homebound. A person who is unable to leave the home without assistance. To be homebound means that leaving home takes considerable and taxing effort.

hospice. A facility or program designed to provide a caring environment while supplying services to meet the physical and emotional needs of the terminally ill and their family.

hospitalist. A doctor who primarily takes care of patients when they are in the hospital. This doctor will take over your care from your primary doctor when you are in the hospital, keep your primary doctor informed about your progress, and will return you to the care of your primary doctor when you leave the hospital.

immunization programs. Preventive care programs designed to monitor and promote the administration of vaccines to guard against childhood illnesses, such as chicken pox, mumps, and measles; and adult illnesses, such as pneumonia and influenza.

independent practice association/independent physician association (IPA). An organization comprised of individual physicians or physicians in small group practices that contracts with MCOs on behalf of its member physicians to provide healthcare services. Also known as independent physician association.

inpatient care. Health care that you receive once you are admitted to a hospital.

length of stay (LOS). The number of days, counted from the day of admission to the day of discharge, that a plan member is confined to a hospital or other facility for each admission.

mammogram. A special x-ray of the soft tissue of the breast.

managed care. Managed care is a complex system that involves the active coordination of, and the arrangement for, the provision of health services and coverage of health benefits. Most health plans in the United States today are some form of managed care. The goal of managed care is to control skyrocketing health care costs without sacrificing the quality of care. In most managed care plans, you can only go to doctors, specialists, or hospitals within the plan’s network; except in an emergency.

managed care organization (MCO). Any entity that utilizes certain concepts or techniques to manage the accessibility, cost, and quality of health-care.

management services organization (MSO). An organization, owned by a hospital or a group of investors, that provides management and administrative support services to individual physicians or small group practices in order to relieve physicians of non-medical business functions so that they can concentrate on the clinical aspects of their practice.

medicaid. A program in the United States, jointly funded by the states and the federal government, that reimburses hospitals and physicians for providing care to qualifying people who cannot finance their own medical expenses.

medically necessary. Services or supplies that are proper and necessary for the diagnosis or treatment of a medical condition, are provided for the diagnosis, direct care, and treatment of a medical condition, and meet the standards of good medical practice.

medicare. A federal government program established under the Social Security Act of 1965 to provide hospital expense and medical expense insurance to elderly and disabled persons.

medicare part A. The Medicare component that provides basic hospital insurance to cover the costs of inpatient hospital services, care in a skilled nursing facility or other extended care facilities after hospitalization, hospice care, and some home health care.

medicare part B. The Medicare component that provides benefits to cover the costs of physicians' professional services, whether the services are provided in a hospital, a physician's office, an extended-care facility, a nursing home, or an insured's home.

network. A group of physicians, hospitals, and other medical care professionals contracted with a managed care plan to deliver medical services to its members.

non-formulary drugs. Drugs not on a plan-approved list.

occupational therapy. Services given to help you return to usual activities (such as bathing, preparing meals, housekeeping) after illness.

out-of-area. Services provided to enrollees by providers that have no contractual or other relationship with the managed care organization. Also includes geographical limitations, such as an out-of-state provider.

out-of-pocket costs. Health care costs that you must pay on your own because they are not covered by your insurance.

outpatient care. Treatment that is provided within the course of one day to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility.

Pap smear test. A test used for early detection of cancer of the cervix, the opening to a woman's womb. It is done by removing cells from the cervix. The cells are then prepared so they can be examined under a microscope to find diseased tissue.

pelvic exam. An exam to check if internal female organs are normal by feeling their shape and size.

physical therapy. The treatment of physical dysfunction or injury by the use of therapeutic exercise and the application of heat, light, exercise, and massage, intended to restore or facilitate normal function or development.

pre-admission testing. Testing, such as x-rays and laboratory tests, that is performed on an outpatient basis and is required prior to a scheduled inpatient stay.

pre-certification. A utilization management policy that requires a plan member or the physician in charge of the member's care to notify the plan, in advance, of plans for a patient to undergo a course of care such as a hospital admission or complex diagnostic test. Also known as prior authorization.

pre-existing condition. A medical condition or health problem you had before the date that a new insurance policy starts.

preferred provider organization (PPO). A managed care option in which you use doctors, hospitals, and providers that belong to a network. You can also use doctors, hospitals, and providers outside of the network for an additional cost.

preventive services. Healthcare designed to keep you healthy and to prevent illness (for example, Pap tests, pelvic exams, flu shots, and screening mammograms). Designed to determine if a health condition is present even if a member has not experienced symptoms of the problem. Also known as preventive screenings or screening programs.

primary care physician (PCP). A physician who serves as a member's first and primary contact with the healthcare system. The PCP ensures members get necessary and preventive care in order to stay healthy. A PCP may also consult other doctors, specialists and healthcare providers, if necessary, and refer care to them. In most managed care plans, you must see your primary care doctor before you see any other healthcare provider. Also known as a primary care provider, personal care physician, or personal care provider.

referral. The process of directing a patient to an appropriate specialist, healthcare provider or facility for treatment. Generally, a referral is defined as an actual document obtained from a provider, typically the Primary Care Physician, referring the member to a specific facility or specialist for service.

retrospective review. A type of utilization review that occurs after treatment is completed in order to determine medical necessity and appropriateness of care, thus leading to either payment authorization or denial. Also known as retro-review.

skilled nursing care. A level of care that includes services that can only be performed safely and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse).

skilled nursing facility (SNF). A facility with the staff and necessary to provide skilled nursing care and/or skilled rehabilitation services and other related healthcare.

specialist. A medical practitioner whose practice is limited to a certain branch of medicine, a particular class or age of patients, certain types of disease, specific body systems, or health problem. A physician who is qualified by advanced training and certification by a specialty examining board and limits his or her practice to an area of expertise.

speech therapy. Treatment of speech defects and disorders, especially through use of exercises and audio-visual aids that develop new speech habits. Designed to strengthen speech skills.

standard of care. The degree of care or competence that a healthcare provider is expected to exercise as well as diagnostic and treatment guidelines that should be followed for a certain type of patient, illness, or clinical circumstance.

urgent care. Care for a sudden illness or injury that needs medical attention right away, but is not life threatening. Your primary care doctor generally provides urgently needed care, but may refer you to another provider depending on the specific situation.

utilization management (UM). Managing the use of medical services to ensure that a patient receives necessary, appropriate, high-quality care in a cost-effective manner.

utilization review (UR). An evaluation of the medical necessity, appropriateness, and cost-effectiveness of healthcare services and treatment plans for a given patient, thereby providing the patient increased assurance of the value and quality of healthcare services.

worker’s compensation. A state-mandated insurance program that provides benefits for healthcare costs and lost wages to qualified employees and their dependents if an employee suffers a work-related injury or disease.