Section 9: Appendix

9.1 Glossary of Terms

Terms/Common Acronyms

Definitions

270 (ANSI ASC X12)Electronic Eligibility/Benefits Request Type of EDI Transaction: Health Care Eligibility/Benefit Inquiry(From Provider)
271 (ANSI ASC X12)Electronic Eligibility/Benefits Response Type of EDI Transaction: Health Care Eligibility/Benefit Response (From Health Plan)
276 (ANSI ASC X12)Electronic Claims Status Request Type of EDI Transaction: Health Care Claim Status Request (From Provider)
277 (ANSI ASC X12)Electronic Claims Status Response Type of EDI Transaction: Health Care Claim Status Notification (From Health Plan)
278 (ANSI ASC X12)Electronic Authorization Certification/Review Information Type of EDI Transaction: Health Care Service Review Information
820 (ANSI ASC X12)Electronic Premium Payment Type of EDI Transaction: Payroll Deducted and other group Premium Payment for Insurance Products
834 (ANSI ASC X12)Electronic Eligibility Type of EDI Transaction: Benefit Enrollment and Maintenance Set
835 (ANSI ASC X12)ERA
(Electronic Remittance Advice)
Type of EDI Transaction: Health Care Claim Payment/Advice Transaction Set (Electronic Remittance)
(ANSI ASC X12)Electronic Claim (837P / 8371) Type of EDI Transaction: Health Care Claim Transaction Set(Inbound / Outbound / Professional / Institutional)

 

A

 
Accountable Care Organization (ACO) A healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients.
Actuary A professional who works with statistics and large numbers. In insurance, an actuary leads analytics, underwriting, pricing, benefit design, and financial performance activities.
Terms/Common Acronyms Definitions
Acuity Bed Level of severity of an illness patient care
Acute Sudden Onset Brief and severe
Acute Care / Urgent Care Short-term medical treatment; urgent medical care
American Dental Association Lobbyist group for American dentists.
Americans with Disability Act Federal law protecting the rights of individuals with disabilities.
Adjudication Processing claims to determine pricing (allowances) and benefits (member liability) amounts.
Adjustment Reprocessing of a claim to make a correction
ADL (Activities of Daily Living) Routine activities that people do every day without needing assistance
Advance Directive (Living Will / Healthcare Power of Attorney) Written statement of a person's wishes regarding medical treatment and how those wishes should be carried out
Adverse Event(Sentinel Event / Never Event) Medical event or error that causes an injury to a patient as the result of a medical intervention rather than the underlying medical condition. It represents an unintentional harm to a patient arising from any aspect of healthcare management.
Adverse Selection The common phenomenon in which healthy people choose not to insure and a disproportionate number of unhealthy people enroll
Affordable Care Act (ACA / PPACA) Enacted to increase quality and affordability of health insurance
Agent/Insurance Agent Person who is employed by the broker, who works with the member, to find an insurance plan that fits their needs to find an insurance plan that fits their needs.
ALOS (Average Length-of-Stay) Metric computed by dividing the total number of in-patient hospital days, in all hospitals, counted from the date of admission to the date of discharge by the total number of discharges (including deaths) in all hospitals during a given year.
AMA (American Medical Association) Physician lobbyist group
Ambulance Vehicle for transportation to provide for medical services
Ambulatory/Outpatient Medical care provided on an outpatient basis (clinic/office or hospital outpatient department)
AMP (Average Manufacturer Price) Average price paid by wholesalers to manufacturers for drugs distributed to retail pharmacies.
Ancillary Provider Providers who provide necessary services within the network of physicians
ANSI (American National Standards Institute) Format for transmitting industry standardized electronic information and forms
AOB (Assignment of Benefits) Accepting payment from a health plan or federal program for services rendered to a patient
APC (Ambulatory Payment Classification / OPPS) A type of outpatient prospective payment system
Appeal Request by the member or provider to change an official decision
Approved Clinical Trial A phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-& threatening disease or condition and is one of the following: a. A Federally funded or approved trial b. A clinical trial conducted under an FDA investigational new drug application; or c. A drug trial that is exempt from the requirement of an FDA investigational new drug application.
ASP (Average Sales Price) Used for pharmacy reimbursement/allowance calculation average price at which a particular product or commodity is sold across channels or markets
Assistant at Surgery / Assistant Surgeon Surgical Tech Defined as a physician or allied health practitioner who actively assists the operating surgeon
Authorization Referral Prior Notification /Prior Authorization Agreement to allow a member to access a specified service
Authorized Representative A person to whom a covered person has given express written consent to represent the Member, a person authorized by law to provide substituted consent for a Member, a family member of the Member or the Member’ treating health care professional if the Member is unable to provide consent, or health care professional if the Member ’s Plan requires that a request for a benefit under the plan be initiated by the health care professional. For any Urgent Care Request, the term includes a health care professional with knowledge of the Member's medical condition.
Auto-Adjudication (Rate) AA/AAR Claims process automatically without pending often improves efficiency and reduces expenses required for manual claims
Avoidable Hospital Conditions Conditions that could reasonably have been prevented through application of evidence-based guidelines. These conditions are not present on admission, but present during the course of the stay. Participating Providers are not permitted to bill the Plan or Members for services related to Avoidable Hospital Conditions.
AWP (Any Willing Provider Average Wholesale Price) Requires managed care plans to accept any qualified provider who is willing to accept the terms and conditions of a managed care plan/Pricing for
pharmaceutical reimbursement/allowances
AWPL (Any Willing Provider Laws) Laws that require managed care organizations to grant network participation to health care providers willing to join and meet the network requirements

 

 

 

 
Metric computed by dividing the total number of in-patient hospital days, in all hospitals, counted from the date of admission to the date of discharge by the total number of discharges (including deaths) in all hospitals during a given year.

B

 
Balance Billing (Also see UC&R) The practice of a healthcare provider billing a patient for the difference between what patient’s health insurance chooses to reimburse and what the provider chooses to charge
Bilateral Procedure Procedures that are performed on both sides of the body during the same procedure.
Brand Name Drug A drug that has a trade name and is protected by a patent

 
 
Metric computed by dividing the total number of in-patient hospital days, in all hospitals, counted from the date of admission to the date of discharge by the total number of discharges (including deaths) in all hospitals during a given year.

C

 
Cafeteria Plan Health plan where members have the option to choose between different types of benefits.
(CAH) Critical Access Hospital A rural hospital (25 beds or less) designated by CMS as a facility that is at least 35 miles from another acute hospital or CAH; receives cost-based reimbursement from CMS.
CAHPS (Consumer Assessment of Healthcare Providers and Systems) The CAHPS Health Plan Survey is a tool for collecting standardized information on enrollees’ experiences with health plans and their services
Calendar Year A period of one year which starts on January 1st and ends December 31st.
Capitation Payment arrangement that pays a physician or group of physicians a set amount for each enrolled person assigned to them.
Carrier (Health Plan) A company that creates and manages insurance products; control underwriting, claims, pricing and overall guidance of the company.
Carve-Out A specifically defined benefit or group of benefits in a plan.
Case Management (CM) A coordinated set of activities conducted for individual Member management of chronic, serious, complicated, protracted, or other health conditions.
Case Rate A pricing method in which a flat amount, often a per diem rate, covers a defined group of procedures and services
Category II CPT Code Codes that describe clinical components usually included in evaluation and management or clinical services
Category Ill CPT Code A temporary set of codes for emerging technologies, services, and procedures
CDC (Centers for Disease Control) Government organization that manages infectious disease protocol and guidelines
(CDHP) Consumer-Directed Health Plan A tier of health plans that allow consumers to manage medical expenses using HSAs, HRAs, or similar payment methods
(CDT) Current Dental terminology Code set for reporting dental services and procedures
Certificate of Creditable Coverage (COC) Document that outlines the dates of coverage for the member through their insurance carrier.
Certification Certification is a determination by the Plan that a request for a benefit has been reviewed and, based on the information provided, satisfies the Plan’s requirements for medical necessity, appropriateness, health care setting, level of care, and effectiveness.
Chemical Dependency / Substance Abuse/ Chem Dep / Substance Use Disorder / CD Addiction to a mood or mind altering drug
CHIP / SCHIP Low-cost health insurance program designed for children of families whose income level was too high to qualify for Medicaid.
Chronic Disease A long-lasting condition that can be controlled but not cured
Claim A bill for services, a line item of service, or all services for one beneficiary within a bill.
Clean Claim A clean claim means a claim that has no defect or impropriety (including any lack of substantiating documentation, including, but not limited to coordination of benefits information) to determine eligibility or adjudicate the claim. A clean claim does not include a claim for payment of expenses incurred during a period of time for which premiums are delinquent or a claim for which fraud or abuse is suspected.
(CHS) Contract Health Services Regulated under IHS, CHS is a secondary program for medical/ dental care provided away from an IHS or tribal health
Clinical Criteria Guidelines that provide recommendations for internal medicine physicians treating patients with certain aliments
Clinical Trial Research studies that test how well new medical approaches work with patients
(CMS)Centers for Medicare and Medicaid Government organization that administers Medicare, Medicaid, CHIP, and parts of the Affordable Care Act (ACA)
CMS-1500 / AKA HCFA-1500 The standard claim form for professional or outpatient claims.
COBRA A continuation of healthcare coverage for a member who leaves their employer.
Coinsurance The percentage of charges to be paid by a Member for Covered Services after the Deductible has been met.
Concurrent Review Concurrent Review is Utilization Review for an extension of previously approved, ongoing course of treatment over a period of time or number of treatments typically associated with Hospital Inpatient care, including care at a Residential Treatment Facility, and ongoing outpatient services, including ambulatory care.
This] Contract or [The] Contract [ The Policy, including all attachments, the Group’s application, the applications of the Subscribers and the Health Maintenance Contract.
Convalescent Care / Rehab / Post-Op A range of health services designed to help people recover from serious illness, surgery or injury
Coordination of Benefits (COB) Ensures a person with multiple insurance policies isn’t compensated more than once
Copay An amount that a Member must pay at the time the Member receives a Covered Service.
CORF (Comprehensive Outpatient Rehabilitation Facility), Outpatient Rehab A medical facility that provides outpatient diagnostic, therapeutic, and restorative services for the rehabilitation of your injury, disability, or sickness.
Cosmetic Involving or relating to treatment intended to restore or improve the person’s appearance..
Cost Sharing Costs that a member is expected to pay as part of their plan
Coverage (CVG) Policy that covers the insured in the event of an unforeseen event
Coverage Gap Time between insurance coverage when a patient is not covered.
Covered Services Those Health Care Services to which a Member is entitled under the terms of their Contract.
CPT Procedure Code /Current Procedure Terminology The code set that describes medical, surgical, and diagnostic services and is designed to communicate uniform information about these services and procedures among physicians, coders, patients, and payers for administrative, financial, and analytical
Credentialing The process of establishing qualifications of licensed professionals and assessing their background.
Creditable Coverage Benefits or coverage provided under: a. Medicare or Medicaid; b. An employer-based health insurance plan or health benefit arrangement that provides benefits similar to or exceeding benefits provided under a health benefit plan; c. An individual health insurance policy; d. Chapter 55 of Title10, United States Code; e. A medical care program of the Indian Health Service or of a tribal organization; f. A state health benefits risk pool; g. A health plan offered under Chapter 89 of Title 5, United States Code; h. A public health plan; i. A health benefit plan under section 5(e) of the Peace Corps Act (22 U.S.C. 2504)(e));j. College plan; or k. A short-term limited-duration policy.

 
 
Metric computed by dividing the total number of in-patient hospital days, in all hospitals, counted from the date of admission to the date of discharge by the total number of discharges (including deaths) in all hospitals during a given year.

D

 
Deductible The amount that a Member must pay each Calendar Year before the Plan will pay benefits for Covered Services.
Dependent The Spouse and any Dependent Child of a Subscriber.
Dependent Child A Subscriber’s biological child; A child lawfully adopted by the Subscriber or in the process of being adopted, from the date of placement;A stepchild of the Subscriber; or A foster child or any other child for whom the Subscriber has been granted legal custody.
DHS (Department of Human Services, HHS (Federal)) Agencies tasked with protecting the health of all Americans and providing essential health services
Diagnosis (DX) Identification of an illness or other problem by examination of the symptoms
Disallowed Amount The difference between the actual amount of the procedure and the amount agreed upon by the insurance company.
Discount Reduction to the prices of services; usually provided when seeing an in network provider
Disease Management A system of coordinated health care interventions and communications for defined patient populations with conditions where self-care efforts can be implemented.
DOI (Department of Insurance) State departments that regulate insurance products and agents.
DOL (Department of Labor) U.S. or State Department of Labor
Domiciliary Care (Dom Care) A supervised living arrangement in a home-like environment for adults who are unable to live alone because of age-related impairments or physical, mental or visual disabilities.
DOS (Date of Service) Date when services were rendered
DRG (Diagnostically-Related Grouping) System used to classify hospital cases
Dual-Eligible Patient is eligible for both Medicare and Medicaid
Durable Medical Equipment (DME) Any medical equipment used in the home to aid in a better quality of living
 
Metric computed by dividing the total number of in-patient hospital days, in all hospitals, counted from the date of admission to the date of discharge by the total number of discharges (including deaths) in all hospitals during a given year.

E

 
(EBSA) Employee Benefits Security Administration An agency within the U.S. Department of Labor; provides information concerning rights under COBRA
(EDI) Electronic Date Inter- change Transfer of data from one computer system to another by standardized message formatting
Efficacy / Effectiveness Determination that a particular course of treatment is effective in managing a health condition
Elective Related to an elective procedure; not medically necessary
Eligible Dependent Any “Dependent” who meets the specific eligibility requirements of the Plan under applicable State and Federal laws and rules.
Eligible Group Member Any Group Member who meets the specific eligibility requirements of the Group’s Plan.
Emergency Medical Condition Sudden and unexpected onset of a health condition that requires immediate medical attention, if failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part or would place the person’s health in serious jeopardy.
EMR (EHR / Electronic Medical Record /Electronic Health Record) Digital version of a paper chart in a clinician’s office
Endodontic Dentistry specialty concerned with the study and treatment of the dental pulp
(EOB) Explanation of Benefits A statement sent by a health insurance company to covered individuals explaining what medical services were paid
EOP (Explanation of Payment / Remittance Advice ) Report that accompanies claims which provides a detailed report on how they were paid, denied, or adjusted
ePrescribing / Electronic Prescribing Allows the physician and other medical practitioners to write and send prescriptions to participating pharmacies electronically
(ERA) Electronic Remittance Advice ANSI transaction for claim payment I remittance.
ERISA (Employee Retirement Income Security Act) Protects the assets of Americans so that funds placed in retirement plans during which the person works will be available
ESRD (End-Stage Renal Disease) Failure of the renal system (kidneys)
Essential Health Benefits (EHB) Based on 10 benefits that are covered across the board: ER, prescription, inpatient/outpatient, therapies, labs, preventative, pediatric, prenatal, mental health/ substance abuse
Exchange / Marketplace, HIX, healthcare.gov State or federal marketplace for the purchasing of health insurance for individuals and small groups
Exclusion Not covered
Expedited Appeal An expedited review involving Urgent Care Requests for Adverse Determinations of Prospective (Pre-service) or Concurrent Reviews will be utilized if the Member, or Practitioner and/or Provider acting on behalf of the Member, believes that an expedited determination is warranted
Experimental Refers to the status of a drug, service, medical treatment or procedure that currently doesn’t present any credible evidence for treatment or diagnosis.
Experimental Drugs Medicinal product that has not yet received approval from governmental regulatory authorities for routine use
Experimental or Investigational Services Health Care Services where the Health Care Service in question either: a. is not recognized in accordance with generally accepted medical standards as being safe and effective for treatment of the condition in question, regardless of whether the service is authorized by law or used in testing or other studies; or b. Requires approval by any governmental authority and such approval has not been granted prior to the service being rendered.