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Pohlys - Glossary of Health Care Terms
Category: Health and Medicine > Health Care
Date & country: 13/09/2007, USA
Words: 949

Criteria that, if unmet, will cause an automated claims processing system to 'kick out' a claim for further investigation.

Effective Date
The date on which a policy's coverage of a risk goes into effect.

An enrollee's decision to join or leave a health plan.

Electronic Claim
A digital representation of a medical bill generated by a provider or by the provider's billing agent for submission using telecommunications to a health insurance payer. Most claims are electronically submitted.

Electronic Data Interchange (EDI)
The automated exchange of data and documents in a standardized format. In health care, some common uses of this technology include claims submission and payment, eligibility, and referral authorization. Refers to the exchange of routine business transactions from one computer to another in a standard format, using standard communications protocols.

Electronic Media Claims
A flat file format used to transmit or transport claims, such as the 192-byte UB-92 Institutional EMC format and the 320-byte Professional EMC NSF.

Electronic Medical Record (EMR)
A computer-based record containing health care information. This technology, when fully developed, meets provider needs for real-time data access and evaluation in medical care. Together with clinical workstations and clinical data repository technologies, the EMR provides the mechanism for longitudinal data storage and access. A motivation for healthcare entities to implement this technology derives from the need for medical outcome studies, more efficient care, speedier communication among pro…

Electronic Remittance Advice
Any of several electronic formats for explaining the payments of health care claims.

Eligible Dependent
Person entitled to receive health benefits from someone else's plan. See also Dependent.

Eligible Employee
Employee who qualifies to receive benefits.

Eligible Expenses
Charges covered under a health plan. See also Covered Services, Approved Services.

Eligible Person
Person who meets the qualifications of a health plan contract.

Elimination Period
Most often used to designate the waiting period in a health insurance policy.

Sudden unexpected onset of illness or injury which requires the immediate care and attention of a qualified physician, and which, if not treated immediately, would jeopardize or impair the health of the Member, as determined by the payer's Medical Staff. Significant in that Emergency may be the only acceptable reason for admission without pre-certification.

Emergency Center, Emergi-center
Non-hospital affiliated health facility that provides short-term care for minor medical emergencies or procedures needing immediate treatment; also called urgi-center, urgent center or free standing emergency medical service center.

Employee Assistance Program (EAP)
A service, plan or set of benefits that are designed for personal or family problems, including mental health, substance abuse, gambling addiction, marital problems, parenting problems, emotional problems or financial pressures. This is usually a service provided by an employer to the employees, designed to assist employees in getting help for these problems so that they may remain on the job. EAP began with a primary drug and alcohol focus with an emphasis on rehabilitating valued employees rat…

Employer Mandate
Under the Federal HMO Act, describes conditions when federally qualified HMOs can mandate or require an employer to offer at least one federally qualified HMO plan of each type (IPA/network or group/staff). Option that federally qualified HMOs have to exercise over employees, requiring them to have available one or more types of HMOs per plan. This requirement was sunsetted in 1995.

Employer Purchasing Coalitions
See Purchasing Alliances.

Employment Model IDS
An integrated delivery system that generally owns or is affiliated with a hospital and establishes or purchases physician practices and retains the physicians as employees.

See Electronic Medical Record

See Emergency Medical Treatment and Labor Act.

A contact between an individual and the health care system for a health care service or set of services related to one or more medical conditions.

Encounter Data
Data relating to treatment or service rendered by a provider to a patient, regardless of whether the provider was reimbursed on a capitated or fee-for-service basis. Used in determining the level of service.

Encounter Report
A report that supplies management information about services provided each time a patient visits a provider.

Enrolled Group
Persons with the same employer or with membership in an organization in common, who are enrolled collectively in a health plan. Often, there are stipulations regarding the minimum size of the group and the minimum percentage of the group that must enroll before the coverage is available. Same as Contract group.

Any person eligible as either a subscriber or a dependent for service in accordance with a contract. The same as beneficiary, individual, or member of a health plan.

Initial process whereby new individuals apply and are accepted as members of a prepayment plan. The total number of covered persons in a health plan. Also refers to the process by which a health plan enrolls groups and individuals for membership or the number of enrollees who sign up in any one group.

Enrollment and Payment System (EPS)
A term used to cover all of the health plan or partner company activities involved in developing and administering its various aspects such as enrollment, payments, appeals, etc.

See Evidence or Explanation of Coverage or Explanation of Benefits

See Exclusive Provider Arrangement.

Episode of Care
A term used to describe and measure the various health care services and encounters rendered in connection with identified injury or period of illness.

See Exclusive Provider Organization.

See Enrollment and Payment System.

See Early and Periodic Screening, Diagnosis, and Treatment.

See External Quality Review Organization.

See Employee Retirement Income Security Act.

Essential Community Providers
Providers such as community health centers that have traditionally served low-income populations.

Ethics in Patient Referrals Act
A federal act which, along with its amendments, prohibits a physician from referring patients to laboratories, radiology services, diagnostic services, physical therapy services, home health services, pharmacies, occupational therapy services, and suppliers of durable medical equipment in which the physician has a financial interest. Also known as the Stark Laws.

Evidence of Insurability (E of I)
Proof of a person's physical condition that effects acceptability for insurance or a health care contract.

Evidence-based Medicine
Evidence-based health care is the conscientious use of current best evidence in making decisions about the care of individual patients or the delivery of health services. Term used in quality improvement and peer review programs in hospitals and health plans.

Excess Charges
Used by CMS to describe in the Medicare Plan the difference between a health care provider's actual charge (which may be limited by Medicare or the state) and the Medicare-approved payment amount.

Excess Risk
Either specific or aggregate stop loss coverage.

Conditions or situations not considered covered under contract or plan. Clauses in an insurance contract that deny coverage for select individuals, groups, locations, properties or risks. Providers will negotiate for exclusions for outliers and carve-out of certain high cost procedures, while payers will negotiate for exclusions to avoid payment of higher cost care.

Exclusivity Clause
A part of a contract which prohibits physicians, providers or other care entities from contracting with more than one managed care organization. Exclusive contracts are common in staff model HMOs and IPAs but becoming less common in other health plan contracting.

Some HMOs compute Plan expansion as part of the capitation rate in order to provide the necessary capital for growth.

A term used to describe the relationship of premium to claims for a plan, coverage, or benefits for a stated time period. Usually expressed as a ratio or percent. See also Medical Loss Ratio.

Experience Rating
The process of setting rates partially or in whole on evaluating previous claims experience for a specific group or pool of groups. The rating system by which the Plan determines the capitation rate or premium rate is determined by the experience of the individual group enrolled, based on actual or anticipated health care use by the specific group of insureds. Each group will have a different rate based on utilization. This system tends to penalize small groups with high utilization. A method of…

Experience-Rated Premium
A premium with is based upon the anticipated claims experience of, or utilization of service by, a contract group according to its age, sex, constitution, and any other attributes expected to affect its health service utilization, and which is subject to periodic adjustment in line with actual claims or utilization experience.

Explanation of Benefits (EOB)
A statement sent to covered individuals explaining services provided, amount to be billed, and payments made. A summary of benefits provided subscribers by the carrier. Same as Evidence of Coverage.

Extended Care Facility (ECF)
A nursing, long-term, or convalescent home offering skilled nursing care and rehabilitation services on a 24-hour basis.

Extension of Benefits
Insurance policy provision that allows medical coverage to continue past termination of employments. See also COBRA.

Favorable Selection
Selection of subscribers or covered lives based on data that shows a tendency for utilization of health services in that population group to be lower than expected or estimated.

Federal Qualification
A status designated by CMS after conducting an extensive evaluation of an HMO's organization and operations. An organization must be federally qualified or be designated as a competitive medical plan (CMP) to be eligible to participate in Medicare and cost and risk contracts. Federal designation that allows an organization to participate in certain Medicare cost and risk contracts.

Federally Qualified HMO
A prepaid health plan that has met strict federal standards and has been granted qualification status. A federally qualified HMO is eligible for loans and loan guarantees not available to non-qualified plans. Employers of 25 or more workers were, until recently, required to offer a federally qualified HMO if the plan requested to be included in the company's health benefits program.

Fee Disclosure
Physicians and caregivers discussing their charges with patients prior to treatment.

Fee Schedule
A listing of accepted fees or established allowances for specified medical procedures. As used in medical care plans, it usually represents the maximum amounts the program will pay for the specified procedures. The fee determined by an MCO to be acceptable for a procedure or service, which the physician agrees to accept as payment in full. Also known as a fee allowance, fee maximum, or capped fee.

Fee-For-Service (FFS)
Traditional method of payment for health care services where specific payment is made for specific services rendered. Usually people speak of this in contrast to capitation, DRG or per diem discounted rates, none of which are similar to the traditional fee for service method of reimbursement. Under a fee-for-service payment system, expenditures increase if the fees themselves increase, if more units of service are provided, or if more expensive services are substituted for less expensive ones. T…

See Fee-For-Service.

Relating to, or founded upon, a trust or confidence. A legal term. A fiduciary relationship exists where an individual or organization has an explicit or implicit obligation to act in behalf of another person's or organization's interests in matters which affect the other person or organization. This fiduciary is also obligated to act in the other person's best interest with total disregard for any interests of the fiduciary. Traditionally, it was generally believed that a physician had a fiduci…

First Dollar coverage
Insurance coverage with no front-end deductible where coverage begins with the first dollar of expense incurred by the insured for any covered benefit.

Fiscal Intermediary
The agent (e.g., Blue Cross) that has contracted with providers of service to process claims for reimbursement under health care coverage. In addition to handling financial matters, it may perform other functions such as providing consultative services or serving as a center for communication with providers and making audits of providers' needs. A private organization, usually an insurance company, that serves as an agent for the Health Care Financing Administration (CMS), which is part of HHS, …

Fiscal Soundness
The requirement that managed care organizations have sufficient operating funds, on hand or available in reserve, to cover all expenses associated with services for which they have assumed financial risk.

Fixed Costs
Costs that do not change with fluctuations in census or in utilization of services.

Flat Fee-Per-Case
Flat fee paid for a client's treatment based on their diagnosis and/or presenting problem. For this fee the provider covers all of the services the client requires for a specific period of time. Often characterizes 'second generation' managed care systems. After the MCOs squeeze out costs by discounting fees, they often come to this method. If provider is still standing after discount blitz, this approach can be good for provider and clients, since it permits a lot of flexibility for provider in…

Flexible Benefit Plan
Program offered by some employers in which employees may choose among a number of health care benefit options. See also Cafeteria Plan.

Flexible Spending Account (FSA)
A plan that provides employees a choice between taxable cash and non-taxable benefits for unreimbursed health care expenses or dependent care expenses. This plan qualifies under Section 125 of the IRS Code. See also Medical Spending Account.

Formatting and Protocol Standards
Data exchange standards which are needed between CPR systems, as well as CPT and other provider systems, to ensure uniformity in methods for data collection, data storage and data presentation. Proactive providers are current in their knowledge of these standards and work to ensure their information systems conform to the standards.

An approved list of prescription drugs; a list of selected pharmaceuticals and their appropriate dosages felt to be the most useful and cost effective for patient care. Organizations often develop a formulary under the aegis of a pharmacy and therapeutics committee. When used by hospitals or clinics, a formulary is intended as a recommendation usually and not considered a requirement. However, when used In HMOs or Prescription Drug Plans, such as Medicare Part D Plans, physicians are often requi…

Federally Qualified Health Center.

Intentional misrepresentations that can result in criminal prosecution, civil liability and administrative sanctions. This is a broad definition and can be applied in many different circumstances. In health care, most commonly it refers to hospitals and doctors that are suspected of charging fees for services not provided or have, in some other way, incorrectly documented a medical record is such a way to increase their revenues or avoid scrutiny.

Freedom of Choice
A principle of Medicaid that allows a recipient the freedom to choose among participating Medicaid providers. This term is also used by indemnity plans to indicate that subscribers may use the providers of their choice.

See Flexible Spending Account.

Fully Funded Plan
A health plan under which an insurer or MCO bears the financial responsibility of guaranteeing claim payments and paying for all incurred covered benefits and administration costs.

Functional Health Status
Refers to a patient`s ability to perform typical daily physical and social/role functions, plus other measures of self-perceived health status such as well-being, vitality and mental health.

Funding Level
Amount of revenue required to finance a medical care program.

Funding Method
System for employers to pay for a health benefit plan. Most common methods are prospective and / or retrospective premium payment, shared risk arrangement, self-funded, or refunding products. See also Self-insured, Risk and Premium.

Funding Vehicle
In a self-funded plan, the account into which the money that an employer and employees would have paid in premiums to an insurer or MCO is deposited until the money is paid out.

Gag Clause
A provision of a contract between a managed care organization and a health care provider that restricts the amount of information a provider may share with a beneficiary or that limits the circumstances under which a provider may recommend a specific treatment option.

A primary care physician, utilization review, case management, local agency or managed care entity responsible for determining when and what services a patient can access and receive reimbursement for. In HMOs, it is commonly an arrangement in which a primary care provider serves as the patient's agent, arranges for and coordinates appropriate medical care and other necessary and appropriate referrals. In that case, the gatekeeper PCP is involved in overseeing and coordinating all aspects of a p…

The process by which a gatekeeper makes the decision where a patient will receive services. In managed care, gatekeeping can also refer to the UR processes of referrals and procedures that must first be preauthorized by an agent of the MCO except in cases of emergency care. See also Gatekeeper.

Generic Drug or Generic Equivalent
A drug which is exactly the same as a brand name drug and which may be manufactured and marketed after the brand name drug`s patent expires (approximately 9-10 years after the brand-name drug entered the market). Generic drugs cost significantly less than brand name drugs, and are identical in terms of efficacy, safety, side effect profile, and dosing. Important exceptions to this may include drugs such as immunosuppressants or drugs with a “narrow therapeutic index� such as anti-arrhythmics. “N…

Generic Substitution
Substituting a generic drug for an identical brand-name drug that has lost its patent protection. Generic substitution lowers drug costs for both consumers and prescription benefit managers while providing equal efficacy, safety, side effect profile and dosing (with a few important exceptions. For more information on exceptions to generic substitution see Formulation Substitution.

The study of how particular traits are passed from parents to children. Identifiable genetic information receives the same level of protection as other health care information under the HIPAA Privacy Rule. Of note for genetic researchers, the rule defines 'identifiable' information to include information from the individual as well as relatives. Thus researchers considering whether to de-identify data should review the definition of de-identified information closely.

Geographic Availability
The number of primary care providers within a given radius of a particular target.

See Financial Services Modernization Act.

Global Budgeting
Limits placed on categories of health spending. A method of hospital cost containment in which participating hospitals must share a prospectively set budget. Method for allocating funds among hospitals may vary but the key is that the participating hospitals agree to an aggregate cap on revenues that they will receive each year. Global budgeting may also be mandated under a universal health insurance system.

Global Fee
A total charge for a specific set of services, such as obstetrical services that encompass prenatal, delivery and post-natal care. Managed care organizations will often seek contracts with hospitals that contain set global fees for certain sets of services. Outliers and carve-outs will be those services not included in the global negotiated rates.

See Group Practice without Walls.

Grace Period
Period past the due date of a premium during which coverage may not be cancelled.

Gramm-Leach-Bliley Act
See Financial Services Modernization Act.

A complaint by an enrollee regarding the way Medicare or a health plan provides its service. Normally, if an enrollee has a complaint about a treatment decision or a service that is not covered, the enrollee will file an appeal, rather than a grievance. Also see Appeal.

Grievance Procedures
The process by which an insured can air complaints and seek remedies.

Gross Charges Per 1,000
An indicator calculated by taking the gross charges incurred by a specific group for a specific period of time, dividing it by the average number of covered members or lives in that group during the same period, and multiplying the result by 1,000. This is calculated in the aggregate and by modality of treatment, e.g., inpatient, residential, partial hospitalization, and outpatient. A measure used to evaluate utilization management performance.

Gross Costs Per 1,000
An indicator calculated by taking the gross costs incurred for services received by a specific group for a specific period of time, dividing it by the average number of covered members or lives in that group during the same period, and multiplying the result by 1,000. This is calculated in the aggregate and by modality of treatment, e.g. inpatient, residential, partial hospitalization, and outpatient. A measure used to evaluate utilization management performance. This is the key concept for the …

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

Group Health Plan Number
A number that is assigned to all group health plans in the future by the CMS division administering the transactions, code sets, security and administrative simplification portions of the Health Insurance Portability and Accountability Act (HIPAA) GSA General Services Administration. See also HIPAA and CMS.

Group Insurance
Any insurance policy or health services contract by which groups of employees (and often their dependents) are covered under a single policy or contract, issued by their employer or other group entity.

Group Market
A market segment that includes groups of two or more people that enter into a group contract with an MCO under which the MCO provides healthcare coverage to the members of the group.

Group Practice
A group of persons licensed to practice medicine in the State, who, as their principal professional activity, and as a group responsibility, engage or undertake to engage in the coordinated practice of their profession primarily in one or more group practice facilities, and who in their connection share common overhead expenses if and to the extent such expenses are paid by members of the group, medical and other records, and substantial portions of the equipment and the professional, technical,…

Group Practice without Walls (GPWW)
Similar to an independent practice association, this type of physician group represents a legal and formal entity where certain services are provided to each physician by the entity, and the physician continues to practice in his/her own facility. It can include marketing, billing and collection, staffing, management, and the like. Also called clinic without walls.