Glossary of Terms

The following terms are commonly used in managed care and in health care. The terms include commonly used definitions.
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
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Access	The patient's ability to obtain appropriate, necessary medical care. The ease of access is determined by several factors, including the availability of services and their acceptability to the patient, the location of health care facilities, transportation, hours of operation, cost of care, languages spoken by health care staff, and telephone coverage.
Acute	The sudden onset of disease or injury, or a sudden change in a person's condition that would require prompt medical attention.
Acute Care	Health care in which a patient is treated for an acute (immediate and severe) episode of illness or injury. Acute care is usually given in a hospital by specialized personnel using complex and sophisticated technical equipment and materials. Unlike chronic care, acute care is often necessary for only a short time.
Admitting Physician	A physician who has the necessary privileges at a hospital to admit patients for care/treatment
Aid to Families with Dependent Children (AFDC) now known as Temporary Assistance for Needy Families (TANF)	The Federal/State AFDC (TANF) program provides cash welfare and Medicaid coverage to needy children and certain others in the household of such child. States administer the program with funding from both the federal government and state. The Personal Responsibility & Work Responsibility Act of 1996, enacted in August 1996, replaced AFDC with a new program called Temporary Assistance for Needy Families (TANF).
Ambulatory Care	All types of health services that are provided on an outpatient basis...for example, in a doctor's office, community health center or clinic...in contrast to services provided to persons who are hospital inpatients.
Ambulatory Surgery	Surgery performed on a non-hospitalized patient. The patient goes home the same day as the surgery.
Ancillary Services	Supplemental services, including lab tests, x-rays, CAT scans and MRIs, that are provided to help diagnose and treat conditions.
Anniversary Date	The beginning of a Member's year of program coverage.
Appeal/Appeal Process	The formal process a provider and/or a Member can use to request review of a Health Plan decision.
Appropriateness	Appropriate health care is care for which the expected health benefit exceeds the expected negative consequences by a wide enough margin to justify treatment. This term is not to be confused with "usual and customary" or "approved" service.
Approval	The term "approval" is usually used to describe a) treatments or procedures that will be covered by the Health Plan because they have been certified by Utilization Review or the referring physician, and b) hospitals, doctors and other providers who have been approved to participate in the Health Plan provider network.
Assess/Assessment	Appraisal of a problem or condition; to estimate or judge the characteristics, qualities or attributes.
Auto-assignment	The process by which Medicaid beneficiaries who do not specify their choice of a health plan within a specified time frame are assigned to a plan by the State or County. Auto-assignment can also refer to the process by which a health plan assigns a Member to a particular PCP if the Member does not make a choice.
Availability	The extent to which services of the correct type and quantity exist.
Average Length of Stay (ALOS)	Refers to the average number of days patients stay in the hospital.
Avoidable hospital condition	Medical diagnoses for which hospitalization may have been avoided if ambulatory care had been provided in a timely and efficient manner.
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Beneficiary	A person eligible to receive benefits. For example, a person who is eligible for the Medicaid program is often referred to as a "Medicaid beneficiary."
Benefit Package	The list of covered services provided by a health care coverage program.
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Capitation (Cap)	A fixed dollar amount, usually paid to a provider for each Member on a monthly basis (i.e., per person per month), to assume responsibility for the Member's health care needs. The capitation payment is made to the provider whether or not the Member uses service during that month.
Carve Out	Services that are excluded from the health plan's benefit package but which are covered for Members directly by the sponsoring government agency.
Case Management	A process and technique to manage the care of specific health care needs (often multiple) in a way that is designed to achieve the optimum patient outcome in the most cost-effective manner.
Case Manager	A nurse, doctor, or other professional who works with patients, providers and insurers to arrange and coordinate all services considered necessary to provide the patient with medically necessary, appropriate health care.
Catastrophic Case	Any medical condition for which the total cost of treatment (regardless of payment source) exceeds levels expected by the health plan.
Center for Medicare and Medicaid Services (CMS), formerly the Health Care Financing Administration (HCFA)	The agency within the U.S. Department of Health and Human Services which administers federal health financing and related regulatory programs, principally the Medicare, Medicaid, and Peer Review Organizations.
Certificate of Authority (COA)	A certificate, issued by a state government, licensing the operation of an HMO or managed care plan.
Claim	A bill, issued by a provider, for services provided to a Member.
Clinical Record	The portion of the medical record that relates to the evaluation, diagnosis, treatment and diagnosis of the patient.
Clinicians	Health care professionals who provide preventive, diagnostic and treatment services to patients.
Commercial Plan	Health insurance policies offered to employers and individual purchasers.
Complaint	A verbal or written expression of dissatisfaction.
Concurrent Review	A method of reviewing patient care, while the care is being delivered (for example, during a patient's hospital stay) to determine if the care is necessary, explore alternatives, and plan for follow-up care.
Confidentiality	Policies and procedures to assure that personal information (for example, patients' medical records) is used only for appropriate purposes, and shared only with those who need such information to serve the patient's needs.
Continuity of Care	The degree to which the care of a patient over time is provided and/or managed by the same provider.
Coordination of Benefits	If an individual has two or more health insurance plans, the process whereby those insurers figure out which pays what portion of the cost of the individual's care.
Co-insurance	A cost-sharing arrangement in which a Member pays a portion of the monthly insurance premium.
Co- payment	A cost-sharing arrangement in which a Member pays a specified fee for a specified service
Credentialing	The process by which a health plan compiles and reviews the qualifications of a provider who applies to participate in a health plan's provider network.
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Days or Visits Per Thousand (per 1,000)	A standard measure by which service utilization rates are expressed, i.e., the number of days, visits, procedures, etc. used in a year for every 1,000 Members.
Deductible	The amount of eligible expense a covered person must pay each year from his/her own pocket before the health plan will make payment for covered services.
Diagnosis Related Groups (DRG)	A system for classifying inpatient hospital services based on diagnosis, age, sex, and the presence of complications.
Drug Formulary	A listing of prescription medications which are preferred for use by the health plan.
Durable Medical Equipment (DME) -	Medical equipment which can stand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of illness or injury, and is appropriate for use at home. Examples of durable medical equipment include hospital beds, wheelchairs, and oxygen equipment.
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Effective Date	The date on which enrollment begins.
Eligibility Guarantee	In the Medicaid managed care and Family Health Plus programs, the provision by which Members may remain enrolled for the balance of their initial six months of enrollment even if they lose Medicaid or Family Health Plus eligibility.
Emergency	A medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in: placing the health of the person afflicted with such condition in serious jeopardy, or, in the case of a behavioral condition, placing the health of the person or others in jeopardy; or serious impairment to such person's bodily functions; or serious dysfunction of any bodily organ or part of such person; or serious disfigurement of such person.
Encounter	A Member visit to a provider for health care services.
Enrollee	A Member.
Enrollment	The word "enrollment" refers to 1) the process of applying for and enrolling in a health plan, and 2) the number of Members enrolled in a health plan.
Enrollment Area	The geographic area in which the health plan may enroll Members.
Exclusions	Specific conditions or circumstances for which the health plan or health care coverage program does not provide benefits.
External Quality Review Organization (EQRO)	An entity that is external to and independent of the State and the health plans, that reviews the services furnished by health plans.
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Fee	A charge or price for professional services.
Fee Schedule	A listing of fees for specified medical or dental procedures.
Fee-For-Service (FFS)	A payment system by which doctors, hospitals and other providers are paid a specific amount for each service provided.
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Grievance	Generally a written expression of dissatisfaction.
Guidelines	Clinical practice parameters, guidelines or protocols, usually established authoritative bodies, that detail the procedures appropriate for the physician to use in making a diagnosis and treating it.
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Health Maintenance Organization (HMO)	An organization that provides, offers or arranges for coverage of designated health services needed by Members for a fixed, prepaid premium, for a defined period of time.
Health Plan	A generic term to refer to HMOs and other managed care programs.
Health Plan Employer Data and Information Set (HEDIS)	Performance measures developed to support health plan and government agency efforts to improve the health status of managed care Members, support the strengthening of health care delivery systems, promote standardization of managed care reporting across public and private sectors, and promote the application of performance measurement technology across programs.
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Lock-in	The period of time during which Members are obligated to remain enrolled in the health plan, i.e., the period of time during which Members may not disenroll (drop out) without having "good cause."
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Managed Care	A system of health care under which the health plan (or managed care organization) is responsible for arranging the delivery, as well as the payment for, services. By managing both the services and the resources to purchase services, health plans attempt to promote the delivery of cost-effective, high quality care.
Management Services Organization (MSO)	An organization that contracts with health plans, other payers and hospitals/physicians to provide management services such as billing and collections.
Medical Loss Ratio	The ratio of health care expenses to premium revenue, i.e., the portion of premium revenue spent on health care.
Medically Necessary	A term used to describe the supplies and services provided to diagnose and treat a medical condition in accordance with the standards of good medical practice and standards of care in the medical community.
Medicare	The federally financed hospital insurance system (part A) and supplementary medical insurance (part B) for the aged created by the 1965 amendment to the Social Security Act.
Member	A person enrolled in a health plan.
Mental Health Provider	A psychiatrist, licensed consulting psychologist, social worker, or hospital or other facility duly licensed and qualified to provide mental health services under the law or jurisdiction in which treatment is received.
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Network Provider	A doctor, hospital or other medical professional who has been approved to participate in a health plan's provider network. (Also referred to as a "participating provider.")
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Open Access or Free Access	A term describing a Member's ability to self-refer for care.
Out-of-Area	Refers to services received by a Member outside the geographical area served by the Member's health plan. Out-of-area coverage generally is restricted to emergency services.
Out-of-Network	Refers to services received by a Member for a provider who is not a participating provider.
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Participating Provider	A doctor, hospital or other medical professional who has been approved to participate in a health plan's provider network. (Also referred to as a "network provider.")
Peer Review	Evaluation of the quality of care, performed by medical personnel with training equivalent to the provider of the care.
Per Diem Cost	Cost per day for hospital or other institutional care.
Per Member Per Month (PMPM)	An indicator of revenue, expenses, or utilization of services expressed in terms of the average amount for each Member each month.
Per Member Per Year (PMPY)	An indicator of revenue, expenses or utilization of services expressed in terms of the average for each Member for each year.
Premium	A predetermined monthly membership fee that a government agency, subscriber or employer pays for health plan coverage.
Preventive health care	Health care that seeks to prevent or foster early detection of disease and morbidity and focuses on keeping patients well.
Primary Care Provider (PCP)	A doctor or nurse practitioner who provides regular and routine care to Members. PCPs usually practice family medicine, pediatrics or internal medicine.
Prior Authorization	The process of obtaining approval for a service before the service is provided.
Prospective Review	A method of reviewing proposed services, for example, hospitalization, before the service takes place, to determine the necessity of the service and possible alternatives to the service.
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Quality Assurance or Quality Management	A formal methodology and set of activities designed to assess the quality of services provided. Quality assurance includes formal review of care, problem identification, corrective actions to remedy any deficiencies and evaluation of actions taken.
Quality Assurance Reporting Requirements (QARR)	The set of performance measures used by New York State to assess the quality of care provided by HMOs and managed care plans serving New York residents.
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Referral	The recommendation by a physician and/or health plan for a Member to receive care from a a physician or facility.
Referral Authorization	A verbal or written approval of a request for a Member to receive medical services or supplies.
Referral Physician	A physician who has a patient referred to him by another source for examination, surgery, or to have specific procedures performed on the patient, usually because the referring source is not prepared or qualified to provide the needed service.
Referring Physician	A physician who sends a patient to another source for examination, surgery, or to have specific procedures performed on the patient, usually because the referring physician is not prepared or qualified to provide the needed service.
Retrospective Review	A method of reviewing patient care, after the service has already been provided, to determine quality, necessity and appropriateness of care.
Risk	An exposure to the chance of injury or financial loss.
Risk Sharing	The process whereby a health plan and a provider or provider organization share financial risk and rewards involved in providing covered services to Members.
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Service Area	The geographic area served by an insurer or health care provider.
Stop-loss	The practice of a health plan protecting itself or its participating providers against part of or all losses above a specified dollar amount incurred in the process of caring for its Members. Usually involves the health plan or insurance company purchasing insurance from another company to protect itself. Also refereed to as reinsurance.
Subscriber/Member	An individual meeting the health plans' eligibility requirement, who enrolls in the health plan and accepts the financial responsibility, if any, for any premiums, copayments, or deductibles.
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Tertiary Care	Medical care requiring highly specialized clinicians and facilities.
Third Party Administrator (TPA)	An organization that administers health care benefits, such as claims review and claims processing.
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Utilization	The use of services.
Utilization Management	The process of evaluating the necessity, appropriateness and efficiency of health care services against established guidelines and criteria.
Utilization Review (UR)	A formal evaluation of the necessity, appropriateness, and efficiency of health care services delivered to a Member, conducted on either a prospective, concurrent or retrospective basis.

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