Glossary: All Entries

Abstract	Accreditation	Accreditation cycle for M+CO
Accreditation for participation	Accredited	Accrediting body
Activities of Daily Living	Actual charge	Actuarial balance
Actuarial deficit	Actuarial rates (Medicare)	Actuarial status
Additional benefits (Medicare)	Adjudicate	Adjusted average per capita cost
Adjustments to payment rates	Administrative data	Admission date
Admitting diagnosis code	Advance beneficiary notice	Advance coverage decision
Advance directives	Advocate	Affiliated contractor
Affiliated provider	Aged enrollee	Allowable
Allowed charge	Ambulatory care	Ambulatory care sensitive conditions
Ambulatory payment classification	Ambulatory surgical center	American Association for Homecare
Ancillary	Annual election period (Medicare)	Appeal
Approved amount	Approved charge	Area Agency on Aging
Assessment	Assigned claim	Assignment
Assignment Of Benefits	Assisted living	Attachment(s)
Attending physician	Authoritative approval	Authoritative evidence
Authorization	Automated claim review	Balance billing
Base estimate	Base payment amount	Basic benefits
Benchmark	Beneficiary	Beneficiary appeal
Benefit payments	Benefits	Benefits description
Benefits package	Blog	Board certified
Body record	Bundling	Cache
Cap rate	Capitation	Capitation rate
Capped rental item	Care plan	Caregiver
Carrier	Case management	Case manager
Case mix	Case mix index	Cash basis
Catastrophic limit	Centers for Medicare and Medicaid Services	Certificate of coverage
Certificate of Medical Necessity	Certified	Certified nursing assistant
Chain of trust	Chain of trust agreement	Civilian Health and Medical Program
Claim	Claim adjustment reason codes	Claim attachment(s)
Claim status category codes	Claim status codes	Classification system
Clearinghouse	Clinical Laboratory Improvement Amendment	Clinical performance measure
Clinical practice guidelines	CMS 1500	CMS contractor policy
Code set	Cognitive impairment	Coinsurance
Complaint of fraud or abuse	Compliance date	Comprehensive MCO
Comprehensive medical insurance	Concurrent review	Conditional payment
Conditions of participation	Consent and authorization (basic rule)	Consolidation omnibus budget reconciliation act
Consultation	Continuation of enrollment	Contract capitation
Contractor	Contractual disallowance	Conversion factor
Cookie	Coordinated care plan	Coordination of benefits
Coordination period	Copayment	Cost report
Cost sharing	Cost-based HMO	Cost-based reimbursement
Coverage	Coverage analysis for laboratories	Coverage basis
Covered benefit	Covered charges	Covered earnings
Covered employment	Covered entity	Covered function
Covered services	Covered worker	Creditable coverage
Cross-over patient	Crosswalk	Current Procedural Terminology
Custodial care	Custodial care facility	Custodian
Customary charge	Data council	Data mapping
Data mapping	Date of service	Deductible
Deemed	Deemed compliance	Deemed status
Deeming authority	Denial	Department of Health and Human Services
Dependent	Designated code set	Designated Data Content Committee
Designated standard	Determination	Diagnosis
Diagnosis code	Diagnosis-related group	Digital imaging and communitcations in medicine
Disability	Disabled enrollee	Disallowance
Discharge planning	Disclosure	Discount drug list
Domain	Downcode	Download
Drug formulary	Drug tiers	Dual eligibles
Durable medical equipment	Durable medical equipment regional carrier	Effective date
Elder care	Election period	Electronic claim
Electronic commerce	Electronic data interchange	Electronic media claims
Electronic remittance advice	Eligibility	Emergency
Employee Retirement Income Security Act	Employer group health plan	Encounter data
Encounter form	Enhanced benefits	Enroll
Enrollment	Enrollment fee	Enrollment period
Entity assets	Episode	Episode of care
Equivalency review	Established patient	Excess charges
Exclusion	Exclusive Provider Organization	Expedited appeal
Expedited organization determination	Expenditure	Explanation of Benefits
External quality review organization	Federal Medicaid Managed Care Waiver Program	Federal qualification
Fee schedule	Fee-for-service	Fiscal intermediary
Fiscal soundness	Fiscal year	Flat file
Flexible benefit option	Food and Drug Administration	Format
Formulary	Formulary drugs	Full capitation
Fully accredited	Gapfilling	Gaps
Gatekeeper	General enrollment period	Generic drug
Global period	Grievance	Group health coverage
Group health plan	Group or network model	Guidelines
Hard copy	HCFA-1500	Health Care Financing Administration
Health Care Prepayment Plan	Health insurance claim form	Health insurance claims number
Health Insurance Portability and Accountability Act	Health insuring organization	Health maintenance organization
Health plan	Health Plan Employer Data and Information Set	Healthcare Common Procedural Coding System
Home & community-based service waiver programs	Home health agency	Home health care
Homebound	Hospice	Hospice care
Hybrid entity	Hyperlink	Hypertext Markup Language
ICD-9-CM	In-network	Incurred basis
Indemnity plan	Independent laboratory	Individual Practice Association
Initial (claim) determination	Initial coverage election period	Initial enrollment period
Initial enrollment questionnaire	Inpatient	Insolvency
Instrumental Activities of Daily Living	Insurance claim form	Insurer
Intermediary	Intermediate entities	IP address
J-codes	Java	Joint Commission on Accreditation of Healthcare Organizations
JPG	Key word(s)	Lifetime reserve days
Limiting charge	Line item	Living will
LMRP Articles	Local code(s)	Local coverage determination
Local medical review policy	Logical observation identifiers, names and codes	Long-term care
Long-term care insurance	Low Utilization Payment Adjustment	Managed care
Managed care organization	Managed care payment suspension	Managed care plan
Managed care plan with a point of service option	Managed care system	Mandatory supplemental benefits
Manual claim review	Manual transmittals	Market basket index
Maximum defined data set	Maximum enrollee out-of-pocket costs	Maximum plan benefit coverage
Medicaid	Medicaid Management Information System	Medicaid MCO
Medicaid-only MCO	Medical code sets	Medical coding
Medical directive	Medical necessity	Medical Records Institute
Medical review	Medical underwriting	Medically necessary
Medicare	Medicare Advantage plan	Medicare benefits
Medicare benefits notice	Medicare billing number	Medicare contractor
Medicare coordination of benefits contractor	Medicare Coverage Advisory Committee	Medicare HMO
Medicare intermediary	Medicare Medical Savings Plans	Medicare Part A
Medicare Part A premium	Medicare Part B	Medicare physician fee schedule
Medicare Preferred Provider Organization Plan	Medicare Private Fee-For-Service Plan	Medicare risk contract
Medicare secondary payer	Medicare Summary Notice	Medicare supplement insurance
Medicare+Choice	Medicare-approved amount	Medigap policy
Modifier	Morbidity	Multi-employer group health plan
Multi-employer plan	Multiple employer plan	National Committee for Quality Assurance
National Coverage Determinations	National Coverage Policy	National Drug Code
National employer ID	National patient ID	National payer ID
National Plan and Provider Enumeration System	National Provider Identifier	National standard per visit rates
National Uniform Claim Committee	Neglect	New patient
NNPI Enumerator	No-fault insurance	Non-covered service
Non-formulary drugs	Non-participating physician	Nonparticipating provider
NPI Registry	NPLANID	Nurse practictioner
Nutrition	Occupational therapy	Offset
Ombudsman	Open enrollment period	Optional supplemental benefits
Organizational determination	Other managed care arrangement	Out of area
Out-of-network	Out-of-pocket expenses	Outcome and Assessment Information Set
Outcome-Based Quality Improvement	Outpatient	Partial capitation
Partially capitated	Participating physician or supplier	Participation
Payer	Peer review	Peer Review Organization
Per diem reimbursement	Per member per month	Periods of care (hospice)
Personal care	Physical therapy	Physician assistant
Physician group	Place of service code	Plan of care
Plan sponsor	Point of service	Portable Document Format
Postpayment review	Potential payments	Pre-existing condition
Preauthorization	Precertification	Preferred provider organization
Premium	Premium surcharge	Prepaid health plan
Prepayment review	Preventive services	Pricer
Primary care	Primary care case management provider	Primary care physician
Primary care provider	Primary payer	Prior authorization
Prior authorization number	Private contract	Private fee-for-service plan
Professional component	Professional Review Organization	Program safeguard contractor
Prospective payment system	Protected Health Information	Provider
Provider number	Provider-Sponsored Organization	Qualified Medicare beneficiary
Quality Improvement Organization	Really Simple Syndication feeds	Reasonable cost
Reasonable-cost basis	Recipient	Recoupment
Referral	Referral services	Regional Home Health Intermediary
Rehabilitation	Reimbursement	Reinsurance
Relative weights	Repricer	Resource-Based Relative Value Scale
Respite care	Review of claims	Risk adjustment
Risk contract	Risk score	Risk selection
Risk sharing	Risk-based health maintenance organization/competitive medical plan	Scan
Scripting language	Second payer	Secondary payer
Self-insured	Server	Shadow claims
Side effect	Single drug pricer	Site
Skilled care	Skilled nursing care	Skilled nursing facility
Small health plan	Social Health Maintenance Organization	Special Election Period
Special Enrollment Period	Specialist	Specialty contractor
Specialty plan	Specified disease insurance	Specified Low-income Medicare Beneficiaries
Speech-language therapy	Spiders	Staff model
Standard claims processing system	Standard transaction	Standardization
Standardized Medreview Instrument	Stop-loss coverage	Subscriber
Supplemental edit software	Supplemental medical insurance	Supplier
Survey	Surveyor	Suspension of payment
Technical component	Telemedicine	Teletypewriter
Term insurance	Third-party payer	Transaction
Transaction change request system	Transient patients	Trauma code development
Treatment	Treatment options	Triage
TRICARE	TRICARE for life	True negatives
Type of service code	UB-04	UB-92
UCR Payment	Unassigned claim	Uncompensated care
Uniform Claim Task Force	Uniform Resource Locator	Unique Physician Identification Number
United Nations Rules for Electronic Data Interchange for Administration, Commerce, and Transport	Update	Urgently needed care
Usual, Customary, and Reasonable	Utilization review	Utilization summary data
Valuation period	Virtual Private Network	Vocational rehabilitation
Voluntary agreement	Voluntary enrollee	Waiting period
Web address	Web browser	Web page
Web server	Weblog	Website
WIFI	WIKI	Withhold
Workers compensation	Workgroup for Electronic Data Interchange	WYSIWYG

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Glossary: All Entries