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Access: Access describes a patient's path to obtaining healthcare. This access is often determined by medical service availability, location of healthcare facilities, hours of operation, and cost.
Accreditation: Evaluations and assessment of the process that determines a stakeholder's degree of compliance in association with their field or industry.
Accrete: This Medicare term describes the process by which new enrollees are added to a health insurance plan.
Activities of Daily Living (ADLs): These are the typical activities included in a person's daily routine. They involve toilet use, bathing, dressing, eating, and moving.
Actuary: An actuary is a type of statistician who computes fiscal-associated insurance risks and premium rates.
Additional Drug Benefit List: This list includes pharmaceuticals that are approved by the health insurance plan. It is sometimes referred to as the drug maintenance list and may describe dispensing quantities along with standards as they relate to the insurance benefits package.
Adjudication: Adjudication describes the judicial procedure of hearing and settling a legal case.
Adjusted Community Rating (ACR): An ACR describes the modification made to a community rating by specific demographics associated with a group.
Adjusted Community Rate Proposal (ACRP): An ACRP is an estimate that describes a Medicare risk plan's per capita revenue requirements in accordance with its ability to provide covered services for an individual's home county. The estimate will be based on factors that include the individual's gender, age, institutional status, employment status, disability, and end-stage renal disease. The HCFA requires Medicare HMOs to submit an ACRP each year.
Administrative Costs: These are the medical management activities and costs that a carrier includes and bills for its administrative services that include processing, enrollment, billing, and overhead costs. These costs may be expressed on a per-member per month basis or as a percentage of premiums.
Administrative Services Only (ASO): ASO describes the management services that a third party provides for an employer group that faces financial risks in associated with the cost of healthcare services. Management services may include medical management service, claim payments processing, and network access. An ASO is a common arrangement when a when a business or organizational employer sponsors a self-funded health benefits program.
Administrator: An administrator is the designated with the responsibility for proper operation of a plan. If the plan sponsor does not designate someone for this role, the ERISA will consider the plan's sponsor to be its plan administrator.
Admission: An admission describes a registered inpatient, someone admitted to a hospital, skilled nursing facility, or another type of medical care facility for at least 24 hours.
Adverse Selection: This term is used to describe those situations where the insurance carrier enrolls a greater degree of risk than the average risk associated with the eligible population.
Aftercare: Aftercare services are any medical or rehabilitation services that follow a hospital stay. These services gradually phase the patient from more intensive treatment to follow-up care designed to prevent relapse and nurture recovery.
Age / Gender Factor: The age / gender factor is a term describing the measurement that underwriters use in association with age and gender risk medical costs in relation from one population group to another. An age / gender factor that exceeds 1.00 is consider a higher-than-average risk, while an age / gender factor that is below 1.00 indicates a lower-than-average demographic risk associated with the expected medical claims.
Age / Gender Rates (ASR): An ASR defines the rates for a group product that also includes a separate rate for various groupings associated with age and gender categories. These rates will be used for billing to calculate group premiums. Many people prefer the ASR because it automatically adjusts to changes within a demographic group.
Agent: An agent must be licensed by the state to provide the services to small businesses and sole proprietors that human resources department provide for large business and corporations. An agent typically does the following: prepare proposal, make informative presentations, explain benefits to employers, delivers policies, performs field underwriting, assists in managing claims, etc...
Aggregate Amount (limit): An aggregate amount describes the maximum limit a plan sponsor such as an employer is liable for a single or series of losses.
Alcoholism: Alcoholism is a medical term that describes a primary and typically chronic disease associated with addiction to alcohol. The disease of alcoholism is associated with psycho-social, genetic, and environmental factors that influence the disease's onset and progression. Alcoholism is characterized by continuous impaired control of drinking. It leads to distortions in thinking and serious health concerns. A person suffering from alcoholism will generally not be able to stop drinking in spite of adverse consequences that include financial, legal, and relationship problems.
Allied Health Personnel: Allied health personnel is a term that describes health workers who are specially trained and often licensed to perform healthcare-related work. They do not include physicians, dentists, optometrists, mental health providers, or nurses who have must have other licensing to practice. Allied health personnel often include all non-physician health workers such as paramedical personnel.
Allowable Costs: These are fees for services that are rendered by a healthcare provider. They qualify as covered expenses.
All-Payer Contract: This is a type of arrangement that allows for a payment of medical services by a contracted insurer regardless of plan type or revue source.
All-Payer System: An all-payer system refers to a plan that charges uniform pricing on healthcare services for all payers.
Alternate Care: Alternate care refers to non-inpatient care that a patient receives in a healthcare setting other than a hospital or inpatient facility such as a skilled nursing facility.
Alternate Delivery Systems (ADS): Traditionally, ADS refers to all forms of medical care delivery except for fee-for medical services. ADS includes plans like PPOs, HMOs, IPAs or other systems to provide medical care.
Alternative Medicine: Alternative medicine describes therapeutic interventions that are used in place of more traditional medical practices. Alternative medicine encompasses the "non-traditional" approaches to the treatment of a disease or condition that are not typically taught in American schools or form part of a Western Medicine school of medicine. They may, however, be associated with other cultural schools of medicine such as those found in Japan, China, or India. Some types of alternative medicine practices include acupuncture and herbal remedies.
Ambulatory Care: Ambulatory care relates to healthcare services that do not involve hospitalization. They are usually delivered in a medical center, doctor's office, or an outpatient healthcare facility.
Ambulatory Setting: An ambulatory setting describes a medical setting where healthcare services are dispensed on an outpatient basis. These settings are typically a day-surgery center, doctor's clinic, or another type of outpatient care facility. Ambulatory settings also include mobile services such as MRI or blood donation mobile units.
American Accreditation Healthcare Commission (AAHC): The AAHC is a partnership that includes representatives from the managed healthcare industry, the public, regulators, and healthcare providers. The AAHC is tasked to review industry standards and review processes for all affected parties. This accrediting body provides the methodology for evaluating and accrediting review programs.
Ancillary Care: This term describes the additional services that are often required during medical treatment and procedures. They include services such as lab work, radiology, and anesthesia.
Ancillary Charge: In addition to copayments, an ancillary charge is the fee that the insured is required to pay at their participating pharmacy for plan-covered brand-name prescription drugs that are preferred for use by the patient or healthcare provider to the generic substitute. This charge is calculated as the difference between the cost of the brand name drug and the MAC list price of the generic substitute.
Any Willing Provider Laws: This describes legislation that requires healthcare plans to accept any physician or healthcare provider like pharmacies into their network if the parties in question are willing to meet all the terms and conditions required by participants.
Appeal: An appeal refers to the formal request to reverse a denial or adverse determination in relation to benefit reimbursement.
Approved Charge: An approved charge indicates the maximum fee amount that Medicate will pay in a defined geographic area for a type of covered service. Providers who don't accept Medicare assignments will not be charged more than 15% of the Medicare fee schedule amount.
Approved Healthcare Facility or Program: This indicates that the program or facility has the license, certification, or appropriate authorization in accordance with state laws to provide healthcare.
Assignment: When contractor providers accept an assignment (i.e. treatment), their provider must accept the amount that is approved by the insurer and pay its fees in full.
Assignment of Benefits: An assignment of benefits occurs when a claimant requests that their claim benefits be paid to an institution or doctor or a designated person.
Attachment Point: In terms of aggregate stop-loss insurance, an attachment point is the point when the stop-loss insurer starts to reimburse the employer based on the collective number of claims paid during the given year.
Average Cost Per Claim: Average cost per claim refers to the average dollar amount that is paid for either administrative or medical services.
Average-Length-of-Stay (ALSO): The ALSO employs a formula to arrive at the number of inpatient days that patients are likely to remain in care at an inpatient facility for a given treatment.
Average Wholesale Price (AWP): AWP refers to the standardized costs of pharmaceuticals which are calculated by averaging the cost of non-discounted drugs charged to a pharmacy by a group of pharmaceutical wholesalers.