Blue Cross and Blue Shield




Kinds of Health care Coverage

Blue Cross and Blue Shield companies countrywide provide health care benefits across the nation and round the world. With use of the concern you’ll need and when it’s needed — Blue Cross and Blue Shield policy owners might have satisfaction when both at home and traveling abroad.

The next includes explanations of the several health care coverage possibilities through Blue Cross and Blue Shield companies.

Health care Coverage within the U.S.

Flexible Investing Account (FSA)

Health Maintenance Organization (HMO)

Health Checking Account (HSA)

Health Compensation Arrangement (HRA)

Indemnity and Traditional Coverage

Point-of-Service (POS)

Preferred Provider Organization (PPO)

When You Are Traveling Within the U.S.

BlueCard®: Abroad Care Program

When You Are Traveling Outdoors from the U.S.

BlueCard Worldwide®

When Working/Living Outdoors from the U.S.

BlueWorldwide Expat

24-hour coverage. An agenda to which an employer’s group health plan, disability plan, and workers’ compensation program get, integrated or matched (based on condition rules) right into a single health benefit plan that covers employees 24 hrs each day.

24-hour handled care. The use of handled care concepts to 24-hour coverage.


access. An individual’s capability to obtain affordable health care on the timely basis.

accreditation. An evaluative process where a health care organization undergoes a test of their operating methods to find out if the methods meet designated criteria as based on the accrediting body, and to make sure that the business meets a particular quality level.1

ACD. See automatic call distributor.

ACF. See ambulatory care facility.

acquisition. Purchasing one organization by another organization.

ACR. See modified community rating.

actuaries. The insurance coverage experts who perform the mathematical analysis essential for setting insurance premium rates.

random committees. Committees which are organised to deal with specific management concerns. Also called special committees.

adequacy. The extent that a network provides the appropriate types and amounts of companies within the appropriate geographic distribution based on the needs from the plan’s people.

modified community rating (ACR). A rating method to which any adverse health plan or MCO divides its people into classes or groups according to demographic factors for example geography, family composition, and age, after which charges all people of the class or group exactly the same premium. The program cannot consider the expertise of a category, group, or tier in developing premium rates. Also called modified community rating.

administrative services only (ASO) contract. An agreement to which a 3rd party administrator or perhaps an insurance provider concurs to supply administrative services for an employer in return for a set fee per worker.

administrative supervision. A scenario by which an MCO’s procedures are put underneath the direction and charge of the condition commissioner of insurance or perhaps a person hired through the commissioner.

adverse event. Any harm someone suffers that’s triggered by factors apart from the patient’s underlying condition.

adverse selection. See antiselection.

agent. An individual who is approved by an MCO or perhaps an insurance provider to do something on its account to barter, sell and repair handled care contracts.

aggregate stop-loss coverage. A kind of stop-loss insurance that delivers benefits whenever a group’s total claims throughout a particular period exceed a mentioned amount.

ambulatory care facility (ACF). A health care center that delivers an array of health care services, including maintenance, acute care, surgery, and outpatient care, inside a centralized facility. Also called a medical clinic or clinic.

ancillary services. Auxiliary or supplemental services, for example diagnostic services, home health services, physical rehabilitation and work therapy, accustomed to support diagnosis and management of a patient’s condition.2

annual and lifetime obtain the most amounts. Maximum dollar amounts set by MCOs to limit the quantity the program be forced to pay for those health care services presented to a customer each year or perhaps in his/her lifetime.

antiselection. The inclination of people that possess a greater-than-average probability of loss to find health care coverage to some greater extent than people who’ve a typical or less-than-average probability of loss. Also called adverse selection.

antitrust laws and regulations. Legislation made to safeguard commerce from illegal restraint of trade, cost discrimination, cost fixing, reduced competition, and monopolies. See also Sherman Antitrust Act, Clayton Act, and Ftc Act.

appeals review committee. The MCO committee that reviews member appeals associated with medical management or coverage determinations.

arbitration. A procedure where the parties to some dispute submit their dispute for an impartial 3rd party for any final, binding decision.

ASO contract. See administrative services only contract.

assets. All products of worth that the company is the owner of.

at-risk. Expression used to explain a provider organization that bears the insurance coverage risk connected using the health care it offers.

authorization. Any adverse health plan’s system of approving payment of advantages for services that fulfill the plan’s needs for coverage.

automatic call distributor (ACD). A tool that solutions calls having a recording machine after which routes calls towards the appropriate department or unit.

autonomy. An ethical principle which, when put on handled care, states that MCOs as well as their companies possess a duty to respect the best of the people to create choices about the path of their lives.3


balance sheet. The financial statement that shows an MCO’s financial status on the specified date.

behavior health care. The supply of mental health insurance and chemical dependency (or drug abuse) services.

benchmarking. An approach to planning and applying quality management programs that includes determining the very best practices and finest final results for any specific process and emulating the very best practices to equal or exceed the very best final results.

beneficence. An ethical principle which, when put on handled care, states that every member ought to be treated in a fashion that respects his very own goals and values which MCOs as well as their companies possess a duty to advertise the great from the people like a group.4

benefit design. The procedure an MCO uses to find out which benefits or the amount of benefits that’ll be agreed to its people, their education that people is going to be likely to share the expense of these benefits, and just how an associate can access health care with the health plan.

guidelines. Actual practices, being used by qualified companies following a latest treatment methods, that produce the very best measurable results on the given dimension.

combined rating. For groups with limited recorded claim experience, an approach to predicting a group’s price of benefits based partially with an MCO’s manual rates and partially around the group’s experience.

Board of Company directors. The main regulating body of the MCO.

brand. A title, number, term, sign, symbol, design or mixture of these components that the organization uses to recognize a number of items.

broker. A sales rep that has acquired a condition license to market and repair contracts of multiple health plans or insurance companies, and who’s ordinarily regarded as a real estate agent from the buyer, not the plan or insurance provider.

budgeting. A procedure which includes developing a financial strategy that the organization thinks will make it achieve its goals, because of the organization’s forecast.

business integration. The unification of a number of separate business (nonclinical) functions right into a single function.



call abandonment rate. A stride of methods frequently people hang up the phone before receiving assistance once they make phone calls to some company and therefore are placed on hold.

capital. The cash that the public company’s proprietors have committed to the organization.

capitation. An approach to having to pay for health care services based on the amount of patients who’re covered for specific services on the number of months as opposed to the cost or quantity of services which are really provided.5

assigned fee. See fee schedule.

captive agents. Agents that represent just one health plan or insurance provider.

carve-out. The separation of the medical service (or several services) in the fundamental group of benefits in some manner.

situation management. A procedure of determining plan people with special health care needs, creating a health-care strategy that fits individuals needs, and matching and monitoring care.

situation-mix adjustment. See risk-adjustment.

unconditionally desperate people. Under initial State medicaid programs qualifications needs, people who received State medicaid programs benefits due to their welfare status.

CCPs. See matched care plans.

Boss. See ceo.

certificate of authority (COA). The license released with a condition for an HMO or insurance provider which enables it to work for the reason that condition.

CHAMPUS (the Civilian Medical and health Program from the U . s . States). See TRICARE.

ceo (Boss). The manager accountable for an organization’s overall operation, general administration and public matters.

chief financial officer. See finance director.

chief information officer (CIO). The manager accountable for the plan’s computer software and hardware systems, its telephone and electronic communication systems and it is electronic commerce abilities.

chief marketing officer. See marketing director.

chief medical officer. See medical director.

chief procedures officer. See director of procedures.

chronic situation. Someone with a number of health conditions that persist for lengthy amounts of time or the patient’s lifetime.

CIO. See chief information officer.

claim. An itemized statement of health care services as well as their costs supplied by a hospital, physician’s office or any other provider facility. Claims are posted towards the insurance provider or handled care plan by either the program member or even the provider for payment from the costs incurred.

claim form. A credit card applicatoin for payment of advantages within health plan.

claimant. The individual or entity posting claims.

claims administration. The entire process of receiving, looking at, adjudicating and processing claims.

claims experts. See claims investigators.

claims investigators. Employees within the claims administration department who consider all the details pertinent to some claim making choices concerning the MCO’s payment from the claim. Also called claims experts.

claims analysis. The entire process of acquiring all the details necessary to look for the appropriate add up to pay on the given claim.

claims administrators. Employees within the claims administration department who oversee the job of countless claims investigators.

Clayton Act. A federal act which prohibits certain actions thought to guide to monopolies, including (1) charging different prices to various customers of the identical product without justifying the cost difference and (2) giving a distributor the authority to sell an item only when the distributor concurs to not sell competitors’ items. The Clayton Act is applicable to insurance providers simply to the extent that condition laws and regulations don’t regulate such activities. See also antitrust laws and regulations.

clinic model. See consolidated medical group.

clinic without walls. See group practice without walls.

clinical integration. A kind of operational integration that allows patients to get a number of health care services in the same organization or entity, which streamlines administrative processes and increases the opportunity of the delivery of high-quality health-care.

clinical practice guideline. A utilization and quality management mechanism made to aid companies for making choices about the best treatment for any specific clinical situation.

clinical practice management. The expansion and implementation of parameters for that delivery of health care services to organize people.

clinical status. A kind of final results measure that pertains to biological health final results.

closed access. A provision which identifies that plan people must obtain medical services only from network companies via a doctor to get benefits.

closed formulary. The supply that only individuals drugs on the preferred list is going to be included in a PBM or MCO.6

closed PHO. A kind of physician-hospital organization that typically limits the amount of taking part specialists by kind of niche.

closed plans. Based on the National Association of Insurance Commissioners’ Quality Assessment and Improvement Model Act, handled care plans that need covered persons to make use of taking part companies.

closed-panel HMO. An HMO whose doctors are generally HMO employees or fit in with several doctors that contract using the HMO.

CMP. See competitive medical plan.

COA. See certificate of authority.

COBRA. See Consolidated Omnibus Budget Reconciliation Act.

coding errors. Documentation errors where a treatment methods are miscoded or even the codes accustomed to describe methods don’t match individuals accustomed to identify diagnosing.

coinsurance. An approach to cost-discussing inside a health insurance plan that needs an organization member to pay for a mentioned area of all remaining qualified medical expenses following the deductible amount continues to be compensated.

communication funnel. An individual, location, or device provided by a business to provide information or services to clients.

community rating. A rating method that sets rates for financing health care based on the health plan’s expected costs of supplying medical good things about the city in general instead of to the sub-group inside the community. Both low-risk and-risk courses are considered into community rating, which propagates the expected health care costs over the entire community.

community rating by class (CRC). The entire process of identifying premium rates where a handled care organization categorizes its people into classes or groups according to demographic factors, industry qualities, or experience and charges exactly the same premium to any or all people of the identical class or group.

compensation committee. The MCO committee that addresses the process of compensation from the Boss and also the MCO’s general compensation and benefit guidelines. An issue, like the capability to demonstrate quality, that can help organizations to compete effectively along with other MCOs for business.

competitive medical plan (CMP). A federal designation that enables MCOs to initiate Medicare insurance risk contracts without needing to obtain federal qualification being an HMO.

complaint. Any adverse health plan member’s expression that his anticipation concerning the product or even the services connected using the product haven’t been met.

computer/telephony integration (CTI). A technology that unites some type of computer system having a telephone system to ensure that the 2 technologies function effortlessly.

computer-based patient record. See electronic permanent medical record.

concurrent review. A kind of utilization review that happens while treatment methods are happening and typically is applicable to services that continue during a period of time.

consolidated medical group. A sizable single medical practice that works in a single or perhaps a couple of facilities instead of in lots of independent offices. The only-niche or multi-niche practice group might be created from formerly independent practices and it is frequently possessed with a parent company or perhaps a hospital. Also called a medical group practice or clinic model.

Consolidated Omnibus Budget Reconciliation Act (COBRA). A federal act which requires each group health intend to allow employees and certain loved ones to carry on their group coverage for any mentioned time period carrying out a being approved event that triggers losing group coverage of health. Being approved occasions include reduced work hrs, dying or divorce of the covered worker, and termination of employment.

consolidation. A kind of merger that happens when formerly separate companies mix to create a new organization with the original companies being dissolved.

contract management system. An info system that includes membership data and provider compensation plans and evaluates transactions based on contract rules.

matched care plans (CCPs). The Medicare insurance Choice delivery option which includes HMOs (without or with a place-of-service component), preferred provider organizations (PPOs), and provider-backed organizations (PSOs).

copayment. A particular amount of money that the member be forced to pay out-of-pocket for any specified service at that time the services are made.

corporate compliance committee. The MCO committee that monitors and guides all compliance activities, including appointment of the corporate compliance officer, approval of compliance program guidelines and methods, overview of the organization’s annual compliance plan, evaluation of internal and exterior audits to recognize potential risks, and implementation of corrective and preventive actions.

corporate compliance director. A professional level health plan manager who accounts for managing the plan’s compliance with condition and federal laws and regulations.

corporation. A business that’s identified by the authority of the governmental unit like a legal entity outside of its proprietors.

cost shifting. The concept of charging more for services presented to having to pay patients or third-party payers to pay for lost revenue caused by services provided free or in a considerably lower cost with other patients.

CRC. See community rating by class.

credentialing. The review and verification process used to look for the current clinical competence of the provider and if the provider meets the MCO’s pre-established criteria for participation within the network.

credentialing committee. The MCO committee that determines and updates credentialing processes and criteria and reviews provider qualifications throughout the credentialing and recred-entialing processes.

credibility. A stride from the record of a routine of the group’s experience.

CTI. See computer/telephony integration.

cure provision. A provider contract clause which identifies a period period (usually 60-3 months) for any party that breaches anything to treat the issue and steer clear of termination from the contract.


data warehouse. A particular database (or group of databases) that contains data from many sources which are linked with a common subject (e.g., an agenda member).7

database marketing. An approach to marketing which involves developing a database of customer information – including demographic, consumer preference and purchasers history information – which is often used to narrow the main focus of the organization’s direct marketing efforts.

decision support system (DSS). A kind of it that utilizes databases and decision models to boost your decision-making process for MCO professionals, managers, clinical staff and companies.8

deductible. A set amount an organization member be forced to pay prior to the insurance provider can make any benefit obligations.

oral health maintenance organization (DHMO). A business that delivers services via a network of companies to the people in return for some type of early repayment.

dental reason for service (dental POS) option. A verbal service plan that enables an associate to make use of whether DHMO network dental professional in order to seek care from the dental professional not within the HMO network. People choose in-network care or out-of-network care at that time they create their dental appointment in most cases incur greater out-of-pocket costs for out-of-network care.

dental POS option. See dental reason for service option.

dental PPO. See dental preferred provider organization.

dental preferred provider organization (dental PPO). A business that delivers dental hygiene to the people via a network of dental practitioners who offer reduced costs towards the plan people.

DHMO. See oral health maintenance organization.

diagnostic and treatment codes. Special codes that contain a short, specific description of every diagnosis or treatment along with a number accustomed to identify each diagnosis and treatment.

direct mail. A marketing medium, usually in publications form, that utilizes a mail plan to distribute an organization’s sales offers or advertising messages.

direct marketing. An approach to marketing that utilizes a number of media to elicit an instantaneous and measurable action – for example an inquiry or perhaps a purchase – from the customer or prospect. Also called direct response marketing.

direct response marketing. See direct marketing.

director of procedures. The manager who runs the programs and services that offer the organization in general, for example enrollment, claims, member services, office management, human assets along with other “back room” functions. Also called a chief procedures officer.


discharge planning. A procedure the MCO uses to assist figure out what activities must occur prior to the patient is prepared for discharge and the best method to conduct individuals activities.

disease management. A matched system of preventive, diagnostic and therapeutic measures meant to provide cost-effective, quality health care for any patient population who’ve or are in danger of a particular chronic illness or medical problem. Also called disease condition management.

disease condition management. See disease management.

distribution. Those activities and systems made to make items or services available to ensure that customers can purchase them.

drive time. The amount of time that people must drive to achieve a principal care provider, that is typically set at no more than fifteen minutes for cities or more to half an hour for rural areas.

drug cards. See pharmaceutical cards.

drug utilization review (DUR). An evaluation program that examines whether drugs are used securely, effectively, and properly.9

DSS. See decision support system.

“dual choice” provisions. Provisions within the HMO Act of 1973 that needed companies that offered health care coverage to a lot more than 25 employees to provide a selection of traditional indemnity coverage or handled health care coverage under whether closed-panel HMO or perhaps an open-panel HMO.

dual eligibles. Seniors and disabled State medicaid programs readers who also be eligible for a Medicare insurance coverage.

due process clause. A provider contract provision which provides companies which are ended with cause the authority to appeal the termination.

DUR. See drug utilization review.


early and periodic screening, diagnostic, and treatment (EPSDT) services. A State medicaid programs program for readers more youthful than 21 that delivers screening, vision, hearing and services at times that meet recognized standards of medical and dental practices and also at other times as necessary to look for the information on physical or mental ailments or conditions.

e-commerce. See electronic commerce.

EDI. See electronic data interchange.

edits. Criteria that, if unmet, may cause an automatic claims processing system to “removeInch claims for more analysis.

electronic commerce (e-commerce). Using computer systems to do transactions and also to facilitate the delivery of health care and non-clinical services for an MCO’s people.

electronic data interchange (EDI). The pc-to-computer transfer of information between organizations utilizing a data format decided through the delivering and receiving parties.

electronic permanent medical record (EMR). A mechanical record of the patient’s clinical, demographic and administrative data. Also called some type of computer-based patient record.

worker benefits consultant. A professional in worker benefits and insurance who’s hired with a group buyer to supply suggestions about any adverse health plan purchase.

Worker Retirement Earnings Security Act (ERISA). An extensive-reaching law that determines the privileges of type of pension participants, standards for that investment of type of pension assets, and needs for that disclosure of plan provisions and funding.

employer buying coalitions. See buying alliances.

employment-model IDS. A built-in delivery system that generally is the owner of or perhaps is associated with a hospital and determines or purchases physician practices and maintains the doctors as employees.

EMR. See electronic permanent medical record.

encounter. A health care visit regardless of the sort by an enrollee to some provider of care or services.

encounter report. A study that supplies management details about services provided every time a patient visits a provider.

enterprise arranging system. An info system that enables physician groups, hospitals along with other facilities inside an enterprise to be the single organization in organizing use of facilities and assets.

EPO. See exclusive provider organization.

EPSDT. See early and periodic screening, diagnostic, and treatment services.

ERISA. See Worker Retirement Earnings Security Act.

error rate. A stride from the precision of knowledge given and transactions processed.

ethics. The concepts and values that advice the actions of the individual or population when dealing with questions of right and wrong.

Ethics in Patient Recommendations Act. A federal act which, together with its changes, forbids your physician from mentioning patients to labs, radiology services, diagnostic services, physical rehabilitation services, home health services, pharmacies, work therapy services and providers of durable medical equipment where the physician includes a financial interest. Also called the Stark Laws and regulations.

exchange. The action of one party giving something of worth to a different party and receiving something of worth in exchange.

exclusive provider organization (EPO). A health care benefit arrangement that’s much like a frequent provider organization in administration, structure, and operation, but which doesn’t cover out-of-network care.

exclusive remedy doctrine. A guide which states that employees who’re hurt at work are titled to workers’ compensation benefits, however they cannot sue their companies for further amounts.

executive committee. The MCO committee accountable for handling the process of overall business policy, including lines of economic and employment guidelines.

executive quality improvement committee. The MCO committee that runs the organization’s quality management committee, accreditation efforts along with other quality functions.

expansion populations. State medicaid programs readers who don’t meet unconditionally desperate or medically desperate criteria and for that reason fall outdoors the standard State medicaid programs population.

expenses. The amounts spent or committed by an MCO to cover covered benefits as well as their administration.

experience. The particular price of supplying health care to some group throughout confirmed duration of coverage.

experience rating. A rating method to which an MCO evaluates a group’s recorded health care costs by type and computes the group’s premium partially or completely based on the group’s experience.

experience-based criteria. A utilization review resource that recognizes generally recognized community standards of practice and also the overall experience and expert opinion of medical company directors along with other health care companies.

expert system. A understanding-based computer whose purpose would be to provide expert consultation to information customers for fixing specialized and sophisticated problems.10

exterior standards. Performance standards that derive from outdoors information for example released industry-wide earnings or guidelines.

extranet. A personal computer network that includes Web-based technologies and links selected assets of the MCO to exterior organizations or people.


fax-on-demand. A communication system that allows an associate to request specified documents or forms simply by entering info on the phone keyboard and also to get the asked for information by fax.

Federal Worker Health Advantages Program (FEHBP). A voluntary medical health insurance program for federal employees, retired people, as well as their loved ones and children.

Ftc Act. A federal act which established the Ftc (Federal trade commission) and gave the Federal trade commission energy to utilize the Department of Justice to enforce the Clayton Act. The main purpose of the Federal trade commission would be to regulate unfair competition and deceitful business practices, that are presented broadly in the process. Consequently, the Federal trade commission also chases violators from the Sherman Antitrust Act. See also antitrust laws and regulations.

fee allowance. See fee schedule.

fee maximum. See fee schedule.

fee schedule. The charge based on an MCO to become appropriate for a process or service, that the physician concurs to simply accept as payment entirely. Also called a fee allowance, fee maximum or assigned fee.

fee-for-service (FFS) payment system. An advantage payment system by which an insurance provider reimburses the audience member or pays the provider directly for every covered medical expense following the expense continues to be incurred.

FEHBP. See Federal Worker Health Advantages Program.

FFS. See fee-for-service payment system.

finance committee. The MCO committee that sets the organization’s broad investment guidelines and accounts for looking at and approving financial and accounting activities.

finance director. The manager who accounts for accounting activities for example budget planning, accounting, and internal audits, and financial procedures for example membership billing and underwriting. Also called a chief financial officer.

financial management. The entire process of controlling an MCO’s financial assets, including management choices concerning accounting and financial confirming, predicting and budgeting.

Financial Services Modernization Act. Legislation that enables convergence one of the typically separate aspects of the financial services industry: banks, investments firms, and insurance providers. Also called the Gramm-Leach-Bliley (GLB) Act.

first contact resolution rate. The share of questions which are clarified, demands which are satisfied and transactions which are processed and completed in the initial reason for contact.

focus group interview. An unstructured, informal session by which six to 10 individuals are brought with a moderator who asks inquiries to advice the group into an in-depth discussion of the given subject.

predicting. A procedure which involves predicting an MCO’s incoming and outgoing cash flows – mainly revenues and expenses – and predicting the values of their assets, liabilities and capital or capital and surplus.

formulary. All of the drugs, indexed by therapeutic category or disease class, which are considered preferred therapy for any given handled population which were designed by an MCO’s companies in prescribing medicines.



fully funded plan. Any adverse health plan to which an insurance provider or MCO bears the financial responsibility of ensuring claim obligations and having to pay for those incurred covered benefits and administration costs.

functional status. A patient’s capability to perform those activities of everyday living.

funding vehicle. Inside a self-funded plan, the account into that the money that the employer and employees might have compensated in rates for an insurance provider or MCO is deposited before the cash is compensated out.


generic substitution. The meting out of the drug that’s the generic same as a drug for auction on a pharmacy benefit management plan’s formulary. Generally, generic substitution could be carried out without physician approval.12

geographic availability. The amount of primary care companies inside a given radius of the particular target.

GLB Act. See Financial Services Modernization Act.

GPWW. See group practice without walls.

Gramm-Leach-Bliley (GLB) Act. See Financial Services Modernization Act.

group market. An industry segment which includes categories of several individuals who enter an organization contract by having an MCO to which the MCO provides health care coverage towards the people from the group.

group model HMO. An HMO that contracts having a multi-niche number of doctors who’re employees from the group practice. Also called an organization practice model HMO.

group practice model HMO. See group model HMO.

group practice without walls (GPWW). A legitimate entity that mixes multiple independent physician practices under one umbrella organization and works certain business procedures for that member practices or arranges of these procedures to become carried out. The GPWW may maintain its very own facility for business procedures or it might hire another company to supply this function. Also called a clinic without walls.


aimless change. Change that’s unplanned and out of control and produces unpredictable results. Also called random change.

HCQIA. See Healthcare Quality Improvement Act.

HCQIP. See Healthcare Quality Improvement Program.

Healthcare Quality Improvement Act (HCQIA). A federal act which exempts hospitals, group practices, and HMOs from certain antitrust provisions because they affect credentialing and peer review as long as these organizations stick to due process standards which are layed out in the process.

Healthcare Quality Improvement Program (HCQIP). A course started through the Healthcare Financing Administration to enhance the standard of care shipped to Medicare insurance enrollees in handled care plans.

health data network. See health information network.

health information network (HIN). Some type of computer network that delivers use of a database of medical information. Also called any adverse health data network.

Medical Health Insurance Portability and Accountability Act (HIPAA). A federal law that outlines the needs that employer-backed group insurance coverage, insurance providers, and handled care organizations must satisfy to be able to provide medical health insurance coverage within the individual and group health care marketplaces.

medical health insurance buying co-operations. See buying alliances.

health covering organization (HIO). A business that contracts having a condition State medicaid programs agency like a fiscal intermediary.

health maintenance organization (HMO). A health care system that assumes or shares both financial risks and also the delivery risks connected with supplying comprehensive medical services to some under your own accord enrolled population inside a particular geographic area, usually in exchange for any fixed, prepaid fee.

Health of Senior citizens Survey. A Healthcare Financing Administration survey that measures Medicare insurance patients’ functional status.

Health Plan Management System (HPMS). A database of knowledge on Medicare insurance Part A and Medicare Part B readers who’re signed up for matched care plans.

health promotion programs. Maintenance programs made to educate and motivate people to avoid illness and injuries and also to promote a healthy body through lifestyle options, for example quitting smoking and nutritional changes. Also called wellness programs.

health risks evaluation. See health risks assessment.

health risks assessment (HRA). A procedure through which an MCO uses details about an agenda member’s health status, personal and family health history, and health-related actions to calculate the member’s probability of going through specific ailments or injuries. Also called health risks evaluation.

health care quality. Based on the Institute of drugs, “their education that health services for people and populations increase the probability of preferred health final results and therefore are in line with current professional understanding.”

high-cost situation. Someone whose condition requires large financial costs or significant human and technological assets.

high-risk situation. Someone that has an intricate or catastrophic illness or injuries or needing extensive medical interventions or treatment plans.

HIN. See health information network.

HIO. See health covering organization.

HIPAA. See Medical Health Insurance Portability and Accountability Act.

HMO. See health maintenance organization.

hold harmless provision. An agreement clause which prohibits companies from seeking compensation from patients when the health plan does not compensate the companies due to insolvency or every other reason.

holding company. A business whose sole clients are the possession of others, that are its subsidiaries.

horizontal division of marketplaces. An illegal business practice that happens when several organizations agree to not compete by dividing geographic marketing areas, product choices, or clients.

horizontal group boycott. An illegal business practice that happens when two rivals agree to not conduct business with another competitor or customer.

hospice care. Some specialized health care services that offer support to crictally ill patients as well as their families.

hospitalists. Doctors who spend a large amount of their amount of time in a hospital setting where they accept admissions for their inpatient services from local primary care companies.

HPMS. See Health Plan Management System.

HRA. See health risks assessment.


IBNR. See incurred although not reported claims.

IDS. See integrated delivery system.

immunization programs. Maintenance programs made to monitor and promote the administration of vaccines to protect against childhood ailments, for example chicken pox, mumps, and measles, and adult ailments, for example pneumonia and influenza.

earnings statement. The financial statement that summarizes an MCO’s revenue and expense activity throughout a particular period.

incorporation by reference. The technique of creating a document part of an agreement by mentioning into it in your body from the contract.

incurred although not reported (IBNR) claims. Claims or benefits that happened throughout a specific period of time, but that haven’t yet been reported or posted for an insurance provider or MCO, so that they remain delinquent.

indemnity wraparound policy. An out-of-plan creation that an HMO offers with an agreement by having an insurance provider.

independent agents. Agents that represent several health plans or insurance companies.

independent exterior review. An appeals review that’s carried out by a 3rd party that’s not associated with the plan or perhaps a providers’ association and it has no conflict of great interest or stake within the results of the review.

independent practice association (IPA). A business composed

of person doctors or doctors in select few practices that contracts with MCOs with respect to its member doctors to supply health care services.

individual market. An industry segment made up of clients not qualified for Medicare insurance or State medicaid programs who’re covered under a person agreement for coverage of health.

individual stop-loss coverage. A kind of stop-loss insurance that delivers benefits for claims with an person that exceed a mentioned amount inside a given period. Also called specific stop-loss coverage.

information management. The mixture of systems, processes and technology that the MCO uses to supply the business’s information customers using the information they have to execute their job duties.

information system. An interactive mixture of people, computer software and hardware, communications products and methods designed use a continuous flow of knowledge to folks who require information to create choices or perform activities.

it. The number of electronic products and tools accustomed to acquire, record, store, transfer or transform data or information.

inside company directors. People of the company’s Board of Company directors who hold positions with the organization additionally for their positions around the Board.

insolvency. A scenario that happens when an organization’s assets or assets aren’t sufficient to pay for its financial obligations and obligations.


integrated delivery system (IDS). A provider organization that’s fully integrated operationally and scientifically use a full-range of health care services, including physician services, hospital services and ancillary services.

integration. For provider organizations, the unification of several formerly separate companies under common possession or control, or even the mixture of the company procedures of several companies which were formerly completed individually and individually.

interactive voice response (IVR) system. An automatic system that solutions calls with recorded or synthesized speech and prompts the caller to reply to a menu of options simply by entering information via a touchtone keyboard or by speaking in to the phone.

internal standards. Performance standards which are produced by the MCO and derive from the organization’s historic performance levels.

Internet. A public, worldwide assortment of interconnected computer systems.

intranet. An interior (private) computer network, built on Web-based technologies and standards, that’s only accessible to people from the computer network.

IPA. See independent practice association.

IPA model HMO. Any adverse health maintenance organization which contracts with a number of associations of doctors in independent practice who accept provide medical services to HMO people.

IVR. See interactive voice response system.


partnership. A kind of partial structural integration by which a number of separate organizations mix assets to attain a mentioned objective. The taking part independent practice associating companies share possession from the venture and responsibility because of its procedures, truly maintain separate possession and treatments for their procedures outdoors from the partnership.

justice/equity. An ethical principle, which, when put on handled care, states that handled care organizations as well as their companies allocate assets in ways that fairly distributes benefits and burdens one of the people.13


large group. A sizable pool of people that coverage of health is supplied through the group sponsor. A sizable group might be understood to be a lot more than 250, 500, 1,000, as well as other quantity of people, with respect to the MCO.

large local groups. Accounts that contract on the local grounds for group worker health advantages. These accounts contrast with national accounts.

period of stay (LOS). The amount of days, counted in the day’s admittance to your day of discharge, that the plan member is limited to some hospital or any other facility for every admission.

length-of-stay recommendations. A utilization review resource that determines a typical inpatient period of stay with different patient’s diagnosis, the seriousness of the patient’s condition and the kind of services and methods recommended for that patient’s care.

liabilities. All financial obligations and obligations of the company.

LOS. See period of stay.

loss rate. The amount and timing of deficits which will exist in confirmed number of insureds as the coverage is within pressure.


mail-order pharmacy programs. Programs that provide drugs purchased and shipped with the mail to organize people in a lower cost.14

handled behavior health organization (MBHO). A business that delivers behavior health services by applying handled care techniques.

handled care. The integration of both financing and delivery of health-care inside a system that seeks to handle the ease of access, cost and excellence of that care.

handled care organization (MCO). Any entity that employs certain concepts or strategies to manage the ease of access, cost and excellence of health care.

handled dental hygiene. Any plan provided by a business that delivers an advantage plan that is different from a conventional fee-for-service plan.

handled indemnity plans. Medical health insurance plans which are given like traditional indemnity plans but including handled care “overlays” for example precertification along with other utilization review techniques.

Management Services Organization (MSO). A business, possessed with a hospital or several traders, that delivers management and administrative support services to individual doctors or select few practices to be able to relieve doctors of non-medical business functions to ensure that they are able to focus on the clinical facets of their practice.

manual rating. A rating method to which any adverse health plan uses the plan’s average knowledge about all groups – and often the expertise of other health plans – as opposed to a particular group’s experience to calculate the group’s premium. An MCO frequently lists manual rates within an underwriting or rating manual.

market segmentation. The entire process of dividing the entire marketplace for a service or product into more compact, more workable subsets or categories of clients.

marketing. The entire process of planning and performing the conception, prices, promotion, and distribution of ideas, goods, and services to produce trades that satisfy individual and business objectives.

marketing director. The manager who runs an organization’s marketing and purchasers activities, including advertising, client relations and enrollment and purchasers predicting. Also called a chief marketing officer.

marketing mix. The 4 major marketing elements-product, cost, promotion, and distribution (place) – that promote the exchange process.

MBHO. See handled behavior health organization.

McCarran-Ferguson Act. A federal act that placed the main responsibility for controlling health insurance providers and HMOs that service private sector (commercial) plan people in the condition level.

MCO. See handled care organization.

State medicaid programs. Some pot federal and condition program that delivers hospital expense and medical expense coverage towards the low-earnings population and certain aged and disabled people.

medical advisory committee. The MCO committee that examines suggested guidelines and action plans associated with clinical practice management, including alterations in provider contracts, compensation, and alterations in authorization methods, reviews data regarding new medical technology and examines suggested medical guidelines.

clinic. See ambulatory care facility.

medical clinic. See ambulatory care facility.

medical director. The plan physician executive who accounts for the standard and price-effectiveness from the health care shipped through the plan’s companies. Also called a chief medical officer.

medical error. An error that happens whenever a planned treatment or procedure is shipped improperly or whenever a wrong treatment or procedure is shipped.

medical foundation. A not-for-profit entity, usually produced with a hospital or health system, that purchases and handles physician practices.

medical group practice. See consolidated medical group.

medical underwriting. The evaluation of health questionnaires posted by all suggested plan people to look for the insurability from the group.

medically appropriate services. Diagnostic or treatment measures that the expected health advantages exceed the expected risks with a margin wide enough to warrant the measures.15

medically necessary services. Services or supplies as supplied by your physician or any other health care provider to recognize and treat a member’s illness or injuries, which, as based on the payer, are in conjuction with the signs and symptoms, diagnosis, and management of the member’s symptom in compliance using the standards of excellent medical practice not exclusively for that ease of the member, member’s family, physician, or any other health care provider and furnished whatsoever intensive kind of health care setting needed through the member’s condition.16

medically desperate people. People who satisfy the financial resource needs of unconditionally desperate people, but whose monthly earnings surpasses specified maximums.

medical-necessity review. See prior authorization.

Medicare insurance. A authorities program established under Title XVIII from the Social Security Act of 1965 to supply hospital expense and medical expense insurance to seniors and disabled persons.

Medicare insurance medical checking account (MSA) plans. The Medicare insurance Choice delivery option that includes a high-deductible catastrophic insurance plan along with a tax-deferred medical checking account established for individual Medicare insurance receivers.

Medicare insurance Part A. The Medicare insurance ingredient that provides fundamental hospital insurance to pay for the expense of inpatient hospital services, confinement in assisted living facilities or any other extended care facilities after hospitalization, home care services following hospitalization, and hospice care.

Medicare insurance Medicare Part B. The Medicare insurance ingredient that provides good things about cover the expense of physicians’ professional services, if the services are supplied inside a hospital, a physician’s office, a long-care facility, a elderly care or perhaps an insured’s home.

Medicare insurance Choose. A Medicare insurance supplement that utilizes a frequent provider organization to supplement Medicare insurance Medicare Part B coverage.

Medicare insurance supplement. A personal medical expense insurance plan that delivers compensation for out-of-pocket expenses, for example insurance deductibles and coinsurance obligations, or benefits for many medical expenses particularly excluded from Medicare insurance coverage.

Medicare insurance Choice. The Medicare insurance ingredient that addresses how covered services are shipped to enrollees and boosts the amounts and kinds of health care organizations permitted to sign up in Medicare insurance.

Medicare supplement guidelines. Individual medical expense insurance plans offered by condition-licensed private insurance providers.

member services. The wide range of activities that the MCO and it is employees undertake to aid the delivery from the guaranteed good things about people and also to keep people pleased with the organization.

Mental Health Parity Act (MHPA). A law which forbids group health plans from using more limited annual and lifetime limits on coverage for mental illness compared to physical illness.

merger. A kind of structural integration that happens when several separate companies are legally became a member of.

messenger model. A kind of independent practice association (IPA) that merely works out a deal car loan terms with MCOs with respect to member doctors, who then contract directly with MCOs while using terms discussed through the IPA. This kind of IPA is most frequently combined with fee-for-service or reduced fee-for-service compensation plans.

MHPA. See Mental Health Parity Act.

MHS. See Military Health System.

Military Health System (MHS). An international health care system operated through the U.S. Department of Defense that focuses its efforts on population health improvement by integrating the delivery of health care services for active-duty personnel, retired people and also the groups of active-duty personnel and retired people.

military treatment facilities (MTFs). Hospitals, treatment centers and centers the Military, Navy, Air Pressure and Coast Guard operate to provide choose to Military Health System receivers.

modified community rating. See modified community rating.

MSA. See Medicare insurance medical checking account plans.

MSO. See Management Services Organization.

MTFs. See Military treatment facilities.

mutual company. A business that’s possessed by its people or policyowners.


national accounts. Large group accounts which have employees in several geographic area which are covered via a single national agreement for coverage of health.17 Contrast with large local groups.

National Specialist Data Bank (NPDB). A database maintained by the us government that consists of info on doctors along with other medical professionals against whom wrongful death claims happen to be settled or any other disciplinary actions happen to be taken.

net gain. The surplus of total revenues over total expenses. Also called profit.

internet loss. If total expenses exceed total revenues, the surplus of total expenses over total revenues.

network. The audience of doctors, hospitals along with other health care professionals that the handled care plan has contracted with to provide medical services to the people.

network management director. Any adverse health plan manager who accounts for developing and controlling the MCO’s provider systems including such activities as prospecting, credentialing, contracting, service, and gratifaction management for companies.

network model HMO. An HMO that contracts using more than one group practice of doctors or niche groups.

start up business underwriting. The danger evaluation an MCO works if this first issues coverage to some group.

Newborns’ and Mothers’ Health Protection Act (NMHPA). A law which identifies that group health plans or group health care insurance companies cannot mandate that hospital stays following giving birth be shorter than 48 hrs for normal shipping or 96 hrs for cesarean births.

NMHPA. See Newborns’ and Mothers’ Health Protection Act.

no balance billing provision. A provider contract clause which states the provider concurs to simply accept the total amount the program will pay for medical services as payment entirely and never to bill plan people for further amounts (aside from co-obligations, coinsurance, and insurance deductibles).

nominating committee. The MCO committee that suggests nominations for company officials as needed within the organization’s bylaws.

non-group market. An industry segment that includes clients who’re covered under a person agreement for coverage of health or signed up for a government program.

non-maleficence. An ethical principle which, when put on handled care, states that handled care organizations as well as their companies are obligated to not harm their people.18

NPDB. See National Specialist Data Bank.


one and done customer support. See first contact resolution rate.

open access. A provision that identifies that plan people may self-make reference to a professional, in both-network or out-of-network, at full benefit or in a reduced benefit, without first acquiring a referral from the primary care provider.

open formulary. The supply that drugs around the preferred list and individuals this is not on the most well-liked list will both be included in a PBM or MCO.19

open PHO. A kind of physician-hospital organization that’s open to all a hospital’s qualified medical staff.

open-panel HMO. An HMO by which any physician who meets the HMO’s standards of care may contract using the HMO like a provider. These doctors typically operate from their own offices and find out other patients in addition to HMO people.

operational integration. The consolidation right into a single operation of procedures which were formerly completed individually by different companies.

final results measures. Health care quality indications that gauge the extent that health care services flourish in enhancing or maintaining satisfaction and patient health.

out-of-pocket maximums. Dollar amounts set by MCOs to limit the total amount an associate needs to shell out of his/her very own pocket for particular health care services throughout a specific period of time.

outpatient care. Treatment that’s presented to someone that can go back home after care with no overnight remain in a hospital or any other inpatient facility.

outdoors company directors. People of the company’s Board of Company directors who don’t hold other positions with the organization.

outsourcing. The employing of exterior suppliers to do specified functions, for example data and knowledge management activities, to have an MCO.


P&T committee. See pharmacy and therapeutics committee.

PACE. See Programs of-inclusive Look after the Seniors.

parent company. A business that is the owner of another company.

patient perception. A kind of final results measure associated with if the patient feels completely “better” after treatment or feels enhanced in comparison to how she or he felt just before undergoing treatment.

PBM. See pharmacy benefit management plan.

PCCM. See primary care situation manager.

PCP. See primary care provider.

peer review. Something where the suitability of health care services shipped with a provider to health plan people is examined with a panel of doctors.

peer review committee. The MCO committee that reviews cases of health care services delivery by which the standard of care is questionable or problematic.


peer review organization (Professional). A business or number of practicing doctors along with other health care professionals compensated by the us government to judge the help supplied by other professionals and also to monitor the standard of care provided to Medicare insurance patients.

pended authorization. An authorization decision that’s postponed.

performance measure. A quantitative way of measuring the standard of care supplied by any adverse health plan or provider that customers, payers, government bodies, yet others may use to check the program or provider with other plans or companies.

personal care physician. See primary care provider.

PFFS. See private fee-for-service plans.

pharmaceutical cards. Identification cards released with a pharmacy benefit management intend to plan people. Prepaid credit cards assist PBMs in processing and monitoring pharmaceutical claims. Also called drug cards or prescription cards.20

pharmacy and therapeutics (P&T) committee. The MCO committee that evolves, updates and supervises the MCO’s formulary and regularly reviews reviews on clinical tests, drug utilization reviews, current and suggested therapeutic recommendations and economic data on drugs.

pharmacy benefit management (PBM) plan. A kind of handled care niche service organization that seeks to retain the costs of prescription medications or pharmaceutical drugs while marketing more effective and safer drug abuse. Also called a prescription benefit management plan.

PHO. See physician-hospital organization.

Physician Practice Management (Parts per million) Company. A business, possessed by several traders, that purchases physicians’ practice assets, provides practice management services, and, generally, gives doctors a lengthy-term contract to carry on employed in their practice and often an equity (possession) position in the organization.

physician-hospital organization (PHO). A partnership from a hospital and several or all its acknowledging doctors whose primary purpose is contract discussions with MCOs and marketing.

plan funding. The technique that the employer or any other payer or customer uses to pay for medical benefit costs and administrative expenses.

planned change. Change that’s deliberate, controlled, collaborative, and positive.

point-of-service (POS) product. A health care option that enables people to select at that time medical services are essential whether or not they will visit a provider inside the plan’s network or seek health care outdoors the network.

pooling. The concept of underwriting numerous small groups as though they constituted one large group.

POS product. See point-of-service product.

PPA. See preferred provider arrangement.

Parts per million. See Physician Practice Management Company.

PPO. See preferred provider organization.

preadmission testing. A utilization management technique that needs plan people who’re scheduled for inpatient choose to have preliminary tests, for example X-sun rays and laboratory tests, carried out with an outpatient basis just before admission.

precertification. A utilization management technique that needs an agenda member or even the physician responsible for the member’s choose to inform the program, ahead of time, of plans for any patient to endure a training course of care like a hospital admission or complex diagnostic test. Also called prior authorization.

pre-existing condition. In group medical health insurance, generally an ailment that a person received health care throughout the 3 several weeks immediately just before the effective date of coverage.

preferred provider arrangement (PPA). As defined in condition laws and regulations, an agreement from a health care insurance provider along with a health care provider or number of companies who accept provide services to persons covered underneath the contract. Good examples include preferred provider organizations (PPOs) and exclusive provider organizations (EPOs).

preferred provider organization (PPO). A health care benefit arrangement made to supply services in a reduced cost by supplying incentives for people to make use of designated health care companies (who contract using the PPO for a cheap price), but that also provides coverage for services made by health care companies who’re not area of the PPO network.

premium. A prepaid payment or number of obligations designed to any adverse health plan by customers, and frequently plan people, for medical benefits.

premium taxes. Condition taxes levied with an insurer’s premium earnings.

prepaid care. Health care services presented to an HMO member in return for a set, monthly premium compensated prior to the delivery of health care.

prepaid group practice. A health care system that provides plan people an array of medical services with an exclusive number of companies in exchange for any monthly premium payment.

prescription benefit management plan. See pharmacy benefit management plan. See pharmaceutical cards.

cost fixing. An illegal business practice that happens when several independent rivals agree with the costs or costs that they’ll charge for services.

prices. The entire process of determining the premium to charge for any health plan or perhaps a given group of benefits.

primary care. General health care that’s provided straight to someone without referral from another physician. It is centered on maintenance and treating routine injuries and ailments.21

primary care situation manager (PCCM). A principal care provider who contracts directly using the condition to supply situation management services, for example coordination and delivery of services, to State medicaid programs patients.

doctor. See primary care provider.

primary care provider (PCP). Your physician or any other healthcare professional who works as a group member’s first connection with a plan’s health care system. Also called a doctor, personal care physician or personal care provider.


primary source verification. A procedure by which a business validates credentialing information in the organization that initially conferred or released the credentialing element towards the specialist.22

prior authorization. Poor a pharmacy benefit management (PBM) plan, a course that needs doctors to acquire certification of medical necessity just before drug meting out. Also called a medical-necessity review. See also precertification.23

private fee-for-service (PFFS) plans. The Medicare insurance Choice delivery option to which coverage is supplied by private insurance service providers instead of through the us government.

Professional. See peer review organization.

process measures. Health care quality indications associated with the techniques and methods that the MCO and it is companies use to furnish service and care.

professionalism. Some qualities or actions that should have our prime standards of the occupation that needs advanced learning a specialized area.

profit. See net gain.

Programs of-inclusive Look after the Seniors (PACE). A residential area-based program, including both Medicare insurance and State medicaid programs, that delivers integrated health care and lengthy-term choose to seniors persons who need a nursing-facility degree of care.

promise keeping/truthtelling. An ethical principle which, when put on handled care, states that handled care organizations as well as their companies possess a duty to provide information honestly and therefore are obligated to recognition obligations.24

promotion. The component of the marketing mix that the organization uses (1) to see customers about its items, the costs of their items, and just how to acquire its items, (2) to influence customers to buy its items, and (3) to help remind customers concerning the benefits connected with transacting business using the organization.

promotion mix. The 4 tools of promotion-advertising, personal selling, sales promotion, and publicity.

prospective review. The review and possible authorization of suggested treatment plans for any patient prior to the treatment methods are implemented.

Provider Manual. A document that consists of information concerning a provider’s privileges and duties included in a network.

provider profiling. The gathering and analysis of knowledge concerning the practice designs of person companies.

buying alliances. In your area based, independently operated organizations that provide affordable group coverage of health to companies with less than 100 employees. Also called buying pools, medical health insurance buying co-operations, employer buying coalitions or buying coalitions.25

buying coalitions. See buying alliances.

buying pools. See buying alliances.

pure community rating. See standard community rating.


QISMC. See Quality Improvement System for Handled Care.

quality. Inside a handled care context, an MCO’s success in supplying health-care along with other services in a way that plan members’ needs and anticipation are met.

Quality Improvement System for Handled Care (QISMC). A Healthcare Financing Administration program made to strengthen MCOs’ efforts to safeguard and enhance the health insurance and satisfaction of Medicare insurance and State medicaid programs enrollees.26

quality management (QM). A business-wide procedure for calculating and enhancing the standard from the health care supplied by an MCO.

quality management committee. The MCO committee that runs the organization’s quality assessment and improvement activities both in clinical and non-clinical areas.


random change. See aimless change.

rate spread. The main difference between your greatest and cheapest rates that the health plan charges small groups. The Nation’s Association of Insurance Commissioners’ Select Few Model Act limits a plan’s allowable rate spread to two to at least one.

rating. The entire process of calculating the right premium to charge customers, because of the amount of risk symbolized through the individual or group, the expected costs to provide medical services and also the expected marketability and competition from the MCO’s plan.

RBRVS. See Resource-Based Relative Value Scale.

reactive change. Change that’s controlled, but rarely planned, which can result in positive, negative, as well as unintentional results.

rebate. A decrease in the cost of the particular pharmaceutical acquired with a PBM in the pharmaceutical manufacturer.27

receivership. A scenario where the condition insurance commissioner, acting for any condition court, takes charge of and supervises an HMO’s liabilities and assets.

recredentialing. An MCO’s periodic overview of the qualifications of the current mobile phone network provider to ensure the provider still meets the standards for participation within the network.

relative worth of services. See relative value scale.

relative value scale (RVS). A technique utilized by MCOs of identifying provider compensation that assigns a weighted value to every surgical procedure or service. To look for the amount the MCO pays towards the physician, the weighted value is increased with a money multiplier. Also called relative worth of services.

renewal underwriting. The procedure through which an underwriter reviews every year all of the selection factors which were considered once the contract was released, then compares the group’s actual utilization rates to individuals the MCO predicted to look for the group’s renewal rate.

reserves. Estimations of cash that the insurance provider must pay future business obligations.

Resource-Based Relative Value Scale (RBRVS). A technique utilized by MCOs of identifying provider compensation that tries to consider, when setting a weighted value to medical methods or services, all assets that doctors use within supplying choose to patients, including physical or procedural, educational, mental (cognitive), and financial assets.

retrospective review. A kind of utilization review that happens after treatment methods are completed to be able to authorize payment and medical necessity and suitability of care.

revenues. The amounts gained from the company’s sales of items and services to the clients.

risk-adjustment. The record adjustment of final results measures to take into account risks which are separate from the standard of care provided and past the charge of the program or provider, like the patient’s gender and age, the importance from the patient’s condition, and then any other ailments the individual may have. Also called situation-mix adjustment.

RVS. See relative value scale.


SCHIP. See Condition Children’s Medical Health Insurance Program.

screening programs. Maintenance programs made to determine whether a physical disease exists even when an associate hasn’t experienced signs and symptoms from the problem.

Section 1115 waivers. Waivers that gave states the legal right to offer more comprehensive services to specified groups of State medicaid programs readers through demonstration projects.

Section 1915(b) waivers. Waivers that permitted states to handle State medicaid programs recipients’ use of companies by setting readers to some primary care situation manager or by enrolling readers within an HMO.


segments. Subsets or workable categories of clients inside a total market. 

self-funded plan. Any adverse health plan to which a company or any other group sponsor, instead of an MCO or insurance provider, is financially accountable for having to pay plan expenses, including claims produced by group plan people. Also called a self-insured plan.

self-insured plan. See self-funded plan.

senior market. An industry segment that’s composed largely of persons over age 65 who’re qualified for Medicare insurance benefits.

service levels. The performance standards that the MCO sets because of its member services activities.

service quality. An MCO’s success in meeting the non-clinical customer support needs and anticipation of plan people.

Sherman Antitrust Act. A federal act which established as national policy the idea of an aggressive marketing system by barring companies from trying to (1) monopolize any kind of trade or commerce or (2) participate in contracts, combinations, or conspiracies in restraint of trade. The Act is applicable to any or all companies involved in interstate commerce and also to all companies involved in foreign commerce. See also antitrust laws and regulations.

site suitability entries. An origin for that overview of surgery and certain nonsurgical interventions that signifies the best configurations for common methods.

select few. Although each MCO’s size limit can vary, generally an organization made up of two to 99 people that coverage of health is supplied through the group sponsor.

special committees. See random committees.

specialist. A health care professional whose practice is restricted to some certain branch of drugs, specific methods, certain age groups of patients, specific body systems or certain kinds of illnesses.28

niche health maintenance organization (niche HMO). A business that utilizes an HMO model to supply health care services inside a subset or single niche of health care.

niche HMO. See niche health maintenance organization.

niche services. Health care services which are generally considered outdoors standard medical-surgical services due to the specialized understanding needed for service delivery and management.

specific stop-loss coverage. See individual stop-loss coverage.

staff model HMO. A closed-panel HMO whose doctors are employees from the HMO.

staffing ratios. Ratios that report the amount of companies within the network to the amount of enrollees within the health plan.

standard community rating. A kind of community rating by which an MCO views only community-wide data and determines exactly the same financial performance goals for those risk classes. Also called pure community rating.

standard of care. A diagnostic and course of treatment that the clinician should follow for any certain kind of patient, illness or clinical circumstance.

standards. “Authoritative claims of: (1) minimum amounts of acceptable performance or results, (2) excellent amounts of performance or results, or (3) the plethora of acceptable performance or results,” based on the Institute of drugs.

standing committees. Lengthy-term advisory physiques on ongoing issues for example finance management, compliance, quality management, utilization management, proper planning and compensation.

Condition Children’s Medical Health Insurance Program (SCHIP). A course, established through the Balanced Budget Act, made to provide health help without insurance, low-earnings children through either separate programs or through broadened qualifications under condition State medicaid programs programs.

legal solvency. An HMO’s capability to maintain a minimum of the minimum quantity of capital and surplus per condition insurance government bodies.

step-lower unit. A ward or portion of a ward inside a hospital that’s dedicated to delivering sub-acute choose to patients following a time of acute care.

stock company. A business that’s possessed through the people and organizations who purchase shares from the company’s stock.

stop-loss insurance. A kind of insurance policy that allows provider organizations or self-funded groups to position a dollar limit on the liability for having to pay claims as well as the insurance provider giving the insurance coverage to pay the insured organization for claims compensated more than a particular yearly maximum.

proper planning committee. The MCO committee accountable for pointing the MCO’s proper direction and goals.

structural integration. The unification of formerly separate companies under common possession or control.

structure measures. Health care quality indications associated with the character, quantity and excellence of the assets that the MCO has readily available for member service and patient care.

subsidiary. A business that’s possessed by another company, its parent.

surplus. The total amount that continues to be when an insurance provider subtracts its liabilities and capital from the assets.


termination provision. A provider contract clause that describes how and under what conditions the parties may finish anything.

termination with cause. An agreement provision, incorporated in most standard provider contracts, that enables either the MCO or even the provider to terminate anything once the other party doesn’t meet its contractual obligations.

termination without cause. An agreement provision that enables either the MCO or even the provider to terminate anything without supplying grounds or offering an appeals process.

the net. See Internet.

therapeutic substitution. The meting out of the different chemical entity inside the same drug class of the drug for auction on a pharmacy benefit management plan’s formulary. Therapeutic substitution always requires physician approval.29

3rd party administrator (TPA). A business that delivers administrative services to MCOs or self-funded health plans but without the financial responsibility for having to pay benefits.

three-tier copayment structure. A pharmacy benefit copayment system to which an associate is needed to pay for one co-payment amount for any generic drug, a greater co-payment amount for any brand-title drug incorporated around the health plan’s formulary, as well as an even greater co-payment amount for any non-formulary drug.

TPA. See 3rd party administrator.

TRICARE. A Department of Defense, regionally handled health care program for active duty and upon the market people from the uniformed services as well as their families that mixes military health care assets and systems of civilian health care professionals. Formerly referred to as CHAMPUS (the Civilian Medical and health Program from the U . s . States).

TRICARE Extra. A lower fee-for-service (FFS) plan like the network part of a PPO.

TRICARE Prime. An enrollment-based handled care option made to provide matched care handled with a primary care manager, who is comparable to a principal care provider inside a commercial HMO.

TRICARE Standard. A fee-for-service plan that enables participants to make use of TRICARE approved companies or non-network companies.

turnaround time. How long needed to accomplish a specific member-started transaction.

two-tier copayment structure. A pharmacy benefit co-payment system to which an associate is needed to pay for one co-payment amount for any generic drug along with a greater co-payment amount for any brand-title drug.

tying plans. An illegal business practice that happens when a business conditions the purchase of 1 service or product around the purchase of other items or services.


UCR. See usual, customary, and reasonable fee.

unbundling. A coding inconsistency which involves separating a process into parts and charging for every part instead of utilizing a single code for the whole procedure. The entire process of determining and classifying the danger symbolized by a person or group.

underwriting problems. Factors that often increase a person’s risk above what is common for age.

underwriting manual. A document that delivers history about various underwriting problems and indicates the right thing to do if such problems exist.

underwriting needs. Needs, sometimes relevant to group qualities or financing measures, that MCOs sometimes impose to be able to provide health care coverage to some given group and which are made to balance any adverse health plan’s understanding of the suggested group with ale the audience to under your own accord choose from the plan (antiselection).

upcoding. A coding inconsistency which involves utilizing a code for any procedure or diagnosis that’s more complicated compared to actual procedure or diagnosis which leads to greater compensation towards the provider.

UR. See utilization review.

URO. See utilization review organization.

usual, customary, and reasonable (UCR) fee. The total amount generally billed for the medical service by doctors inside a particular geographic region. UCR costs are utilized by traditional health insurance providers because the grounds for physician compensation.

utilization recommendations. A utilization review resource that signifies recognized approaches to look after common, simple health care services.

utilization management (UM). Controlling using medical services to make sure that someone receives necessary, appropriate, high-quality care inside a cost-effective manner.

utilization management committee. The MCO committee that reviews and updates the MCO’s utilization management program, determines utilization review methods, reviews referral and utilization designs and reviews utilization choices for medical suitability.

utilization review (UR). An assessment from the medical necessity, suitability and price-effectiveness of health care services and treatment plans for any given patient.

utilization review organization (URO). An exterior organization that conducts reviews to evaluate the medical suitability of recommended protocols for patients, therefore supplying the individual and also the customer elevated assurance from the value and excellence of health care services.


variances. The variations acquired from subtracting actual is a result of expected or allocated results.


wait time. The amount of time, normally, that people must remain on the phone before they receive assistance.

website. A particular location on the internet that delivers customers use of several related text, graphics, and, in some instances, multimedia and interactive files.

wellness programs. See health promotion programs.

WHCRA. See Women’s Health insurance and Cancer Privileges Act.

withhold. A portion of the provider’s payment that’s “held back” throughout the program year to offset or purchase any cost overruns for referral or hospital services. Any area of the withhold not employed for these reasons is distributed to companies.

Women’s Health insurance and Cancer Privileges Act (WHCRA). A law which requires health plans that provide medical and surgical benefits for mastectomy to supply coverage for rebuilding surgery following mastectomy.

workers’ compensation. A condition-mandated insurance program that delivers benefits for health care costs and lost pay to qualified employees as well as their loved ones if the worker suffers a piece-related injuries or disease.

workers’ compensation indemnity benefits. Benefits that replace an employee’s wages as the worker is not able to operate due to a piece-related injuries or illness.

Internet (World wide web). An Online service that links individually possessed databases that contains text, pictures and multimedia elements. Also called the net.

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