last 50 terms

Administrative Services Organization (ASO)

An arrangement where an insurance company, for a fee, processes claims and handles paperwork for a self-funded group, usually excluding assumption of risk.

Allied Health Personnel

Trained and licensed health workers other than physicians, dentists, optometrists, chiropractors, podiatrists, and nurses; sometimes called paramedical personnel.

Alternate Delivery Systems

Health services provided outside an inpatient, acute-care hospital, or private practice, such as skilled nursing facilities, hospice, and home health care, designed to be more cost effective.

Ancillary Services (Ancillary Charges)

Supplemental services like laboratory, radiology, physical therapy, and inhalation therapy provided alongside medical or hospital care.

Attending Physician

The physician with primary responsibility for diagnosis and treatment of a patient, or one with privileges to practice a specialty independently.

Avoidable Hospital Condition

A medical diagnosis for which hospitalization could have been avoided if timely, efficient ambulatory care had been provided.

Beneficiary

A person eligible to receive insurance benefits.

Benefits

Specific areas of plan coverage, such as outpatient visits and hospitalization, that make up the medical services a payer offers to subscribers.

Billed Charges

The actual dollar amount billed by a doctor or other health care provider for a particular service.

Cafeteria Plan

A corporate benefits plan letting employees choose among two or more benefits consisting of cash and qualified benefits; also called a flex plan.

Care Management

Helps achieve better health outcomes by anticipating and linking patients with needed services quickly, while avoiding unnecessary testing and care.

Channeling

Use of incentives and plan design to encourage members to use network providers.

Chronic Disease

A disease that persists over a long period (more than 30 days), is not curable, and/or recurs frequently.

Clinical or Critical Pathways

A "map" of preferred treatment and intervention activities outlining needed information, timelines, and actions, developed by clinicians for specific diseases or events.

Continuity of Care

The degree to which a patient's care from onset of illness to completion is continuous, without interruption.

Continuum of Care

Clinical services provided during a single hospitalization or across multiple conditions over a lifetime, used to evaluate quality, cost, and utilization long term.

Credentialing

Examination of a provider's credentials to determine eligibility for clinical privileges at a hospital or a contract with an MCO.

Critical Pathways

A schedule of critical care and medical/nursing procedures designed for efficient, coordinated treatment using a "best practice" standard.

Durable Medical Equipment (DME)

Equipment that can be repeatedly used for a medical purpose, generally not useful absent illness or injury, and appropriate for home use.

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

A program covering screening and diagnostic services to find physical or mental defects in recipients under 21, plus care to correct or improve them.

Encounter

A member visit to a medical group with the intent of seeing a health care provider, which may include an office visit, lab test, or immunization.

Enrollee

A person eligible to receive, or receiving, benefits from an HMO or insurance policy, including subscribers and their eligible dependents.

EOB (Explanation of Benefits)

A document provided to an insured and provider after services are rendered, summarizing how a claim was paid based on the benefit plan.

Episode of care

All treatment rendered in a specified time frame for a specific disease.

ERISA

The Employee Retirement Income Security Act of 1974, the first federal law protecting the rights of workers who earn pension benefits, requiring plan administrators to meet reporting and fiduciary standards.

Events

Any medical service a patient receives, including hospitalizations, outpatient procedures, diagnostic tests, or physical therapy.

Federal Employees Health Benefits Program (FEHBP)

The health benefits program for federal employees, administered through the U.S. Office of Personnel Management.

Freestanding Emergency Medical Service Center

A health care facility physically and financially separate from a hospital, providing immediate short-term care for urgent conditions; also called an emergicenter.

Gatekeeper Model

A primary care case management model requiring all non-emergency care to be authorized by a member's primary care physician before it's rendered.

Hospital Day

A 24-hour period, starting at a hospital's designated time, during which a patient receives hospital services.

Integrated Health Care System

Health care financing and delivery organizations providing a continuum of care so patients get the right care, at the right time, from the right provider.

Legend Drug

A drug that, by law, can only be obtained by prescription and carries the label warning against dispensing without one.

Maintenance Medication

Medications prescribed for long-term treatment of chronic conditions, such as diabetes, high blood pressure, or asthma.

Managed Care Organization (MCO)

An organization accountable for the health of an enrolled group, such as an HMO, PPO, or POS, that manages risk, contracts with providers, and handles claims.

Medical Protocols

Guidelines providing caregivers with specific treatment options for particular clinical symptoms or data, built from accumulated clinical outcome databases.

Outcome

The finding of a diagnostic procedure, or the results for a patient after care, such as how long it took to restore ability to walk or work.

Partial Hospital Services

A mental health or substance abuse program operated by a hospital, providing clinical services as an alternative or follow-up to inpatient care.

Physical Therapy

Rehabilitation concerned with restoring function and preventing physical disability after disease, injury, or loss of a body part.

Physician Dispensing

When a physician gives a patient initial doses of a commonly prescribed drug during an office visit, with refills typically done at a pharmacy.

Practice Guidelines

Systematically developed statements assisting practitioners in making decisions about appropriate care for specific conditions, often used by MCOs to evaluate necessity.

Principal Diagnosis

The medical condition ultimately determined to have caused a patient's hospital admission, used to assign a diagnosis-related group.

Privileges

Authority granted, usually by a hospital, allowing a provider to perform services there, with varying levels such as courtesy, provisional, or admitting.

Quality

A measure of how well delivered health services meet established professional standards and consumer judgments of value.

Home Care

Medical care ordinarily administered in a hospital or outpatient setting but instead given at a patient's residence when they aren't sufficiently ambulatory.

Sentinel Event

An adverse health event that could have been avoided through appropriate and medically necessary care.

Telemedicine

The provision of consultant services by off-site physicians via technology like closed-circuit television, allowing remote patient examination.

Triage

The evaluation of patient conditions for urgency and seriousness, establishing a priority list for treating multiple patients.

Utilization Review (UR)

A review by the health plan to see if a provider is spending plan money on treatment in line with peers, used partly to determine withhold fund distribution.

Work-up

The total patient evaluation, which may include assessments, radiologic series, medical history, and diagnostic procedures.

Third Party Administrator (TPA)

An outside organization that handles administrative duties and sometimes utilization review for organizations that fund health benefits but don't want to administrate the plan themselves.