Language
Managed
of
Health Care
A glossary of
terms used in
health care
management
and organized
health care
systems
Published by
United HealthCare Corporation
9900 Bren Road East
Minnetonka, MN 55343
(612) 936 -1300
Introduction 5
Definition of Terms 9
Common Abbreviations
and Acronyms in
Managed Health Care 77
INTRODUCTION
— The Editors
A
access — a patient’s path to obtain medical
care. The ease of access may be determined
by the availability of medical services and
their acceptability to the patient, e.g., the
location of health care facilities, transportation,
hours of operation and cost of care.
C
calendar year — the inclusive period of
time from January 1 of any year through
December 31 of the same year. Most often
used in connection with deductible amount
and out-of-pocket provisions of major medical
plans providing benefits for expenses
incurred within the calendar year. Also
found in provisions outlining benefits
in basic hospital, surgical, medical plans.
D
date of service — the date health care
services were provided to the covered person.
E
effective date — the date a contract
becomes active.
electronic data interchange (EDI) — the
computer-to-computer exchange of business or
other information between two organizations
(trading partners). The data may be either in
a standardized or proprietary format. Also known
as electronic commerce.
effectiveness/efficacy of treatment —
the probability of benefit to individuals
from a medical treatment. Effectiveness refers
to ordinary conditions (e.g., by the average
practitioner for the typical patient) whereas
efficacy refers to ideal conditions (e.g., within
a controlled research trial).
experimental, investigational or
unproven procedures — generally, health
care supplies, treatments, procedures, drug
therapies or devices that are determined to be:
not generally accepted by informed health care F
professionals in the United States as effective
in treating the condition, illness or diagnosis
for which their use is proposed; not proven
by scientific evidence to be effective in treating
the condition, illness or diagnosis for which
their use is proposed; or undergoing scientific
study to determine safety and efficacy.
explanation of benefits (EOB) — the
coverage statement sent to covered persons
listing services rendered, amount billed and
payment made.
F
facility — a physical location where health
care/services are provided, such as a hospital,
clinic,emergency ro o mo ra m b u l a t o r yc a re center.
fee-for-service reimbursement —
traditional health care payment system, that
provides physicians and other health care
providers with a payment that does not
exceed their billed charge for each unit
of service provided.
H
HCFA 1500 — a universal form, developed
by the government agency known as Health
Care Financing Administration (HCFA), for
providers of services to bill professional fees
to health carriers.
HCFA Common Procedural Coding
System (HCPCS) — a listing of services,
procedures and supplies offered by physicians
and other providers. HCPCS includes CPT
(Current Procedural Terminology) codes,
national alpha-numeric codes and local
alpha-numeric codes. The national codes are
developed by HCFA in order to supplement
CPT codes. They include physician services
not included in CPT as well as non-physician
services such as ambulance, physical therapy
and durable medical equipment. The local
codes are developed by local Medicare
carriers to supplement the national codes.
HCPCS codes are five-digit codes, the first
digit is a letter that is followed by four
numbers. HCPCS codes beginning with
A through V are national; those beginning
with W through Z are local.
H
health care prepayment plan (HCPP) —
a cost contract with the Health Care Financing
Administration that prepays a health plan
a flat amount per month to provide Medicare-
eligible Part B medical services to enrolled
members. Members pay premiums to cover
the Medicare coinsurance, deductibles and
copayments, plus any additional non-Medicare
covered services that the plan provides.
The HCPP does not arrange for Medicare
Part A services. (Eliminated by the Balanced
Budget Act effective Dec. 31, 1998, except
for plans sponsored by a union or employer.)
I
impairment — any loss or abnormality of
psychological, physiological or anatomical
structure or function (e.g., hearing loss).
L
late entrant — any member applying
for coverage after the expiration of the initial
or open enrollment period. Late entrants may
be subject to a pre-existing condition limitation.
HIPAA rules govern certain late entrants.
M
M
maintenance list— see additional drug benefit list.
major diagnostic category (MDC) — a
clinically coherent grouping of ICD-9-CM
diagnoses by major organ system or etiology
that is used as the first step in assignment
of most diagnosis related groups (DRGs).
MDCs commonly are used for aggregated
DRG reporting.
multidisciplinary — determination
of treatment plans and delivery of care
provided by professionals across a wide
range of specialties.
N
National Committee for Quality
Assurance - (NCQA) — a private,
not-for-profit organization governed by
purchasers of health care (employers and
government), health plans and consumers,
that accredits health plans and develops
performance measures known as HEDIS.
O
office visit — provision of physician or
nursing services in an office setting.
P
paid claims — the amounts paid to satisfy
the contractual liability of the carrier or plan
sponsor. These amounts do not include any
covered person liability for ineligible charges
or for deductibles or copayments. If the
carrier has preferred payment contracts with
providers (e.g., fee schedules or capitation
arrangements), lower paid claims liability
usually result.
R
Q
qualified Medicare beneficiary (QMB) —
a person whose income falls below 100% of
federal poverty guidelines, for whom the state
must pay the Medicare Part B premiums,
deductibles and copayments.
R
rate — the amount of money per enrollment
classification paid to a carrier for medical
coverage. Rates usually are charged on
a monthly basis.
S
Selling, General and Administrative
Expenses (SG&A) — all operating expenses
except the actual cost of paid health benefits
(i.e., medical costs).
T
table rates — see age/gender rates.
Tax Equity and Fiscal Responsibility Act
of 1982 (TEFRA) — the federal law that
created the risk and cost contract provisions
under which health plans contracted with
HCFA and defined the primary and secondary
coverage responsibilities of the Medicare
program. (Superceded by the Balanced
Budget Act of 1997.)
U
unbundling — separately packaging costs
or services that might otherwise be billed
together. For claims processing, this includes
providers billing separately for health care
services that should be combined according
to industry standards or commonly accepted
coding practices.
V
voluntary formulary — see drug formulary.
Common Abbreviations and Acronyms in
Managed Health Care
Cap — capitation
CR — carrier replacement
DC — dual choice
DO — doctor of osteopathy
DX — diagnosis code
EOM — end-of-month
EOY — end-of-year
FFS — fee-for-service
LOS — length-of-stay
MD — medical doctor
MDC — major diagnostic category
OA — open access
OOA — out-of-area
OON — out-of-network
OOP — out-of-pocket costs/expenses
OTC — over-the-counter
QA — quality assurance
QM — quality management
SVC — service
UM — utilization management
VE — voluntary effort
YTD — year-to-date
NOTES