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Health Insurance Terms Glossary

February 20, 2020

Table of Contents

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A B C D E F G H I J K L M
N O P Q R S T U V W X Y Z

A

 

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access to healthcare National Policy A person’s ability to obtain affordable medical care on a timely basis. [3]
accreditation Performance Management An evaluative process in which a health care organization undergoes an examination of its operating procedures to determine whether the procedures meet designated criteria as defined by the accrediting body and to ensure that the organization meets a specified level of quality.
[3]Related to: licensure
accumulator Performance Management An accumulator is a counter of like events which have occurred. New claims can be compared to a set of accumulators to determine whether they are consistent with a “usual pattern” of utilization. This can be helpful in identifying anomalies of utilization of services, including possible abuse and fraud.
[15]
actuarial management Scheme Policy Actuarial management uses financial modeling of products affected by member demographics and actuarial projections to fine-tune benefit design and attract a balanced pool of risks. Tools for actuarial management in the health insurance industry include underwriting and risk-based pricing, and the maintenance of actuarial reserves.
[19]
actuarial projections Scheme Policy An actuarial projection is a prediction of monies which the insurance scheme will need to pay out in a following period (next year, next 5 years, etc.) This prediction is based on many factors, some quantitative, some qualitative. A good actuary will attempt to understand the health of the population and the trend in that health status, the costs of medical care (called medical loss ratio) and the trend in those costs, the expectations for services from the population, the introduction of new medical technologies and their impacts, etc. [15]
actuarially sound Performance Management A health plan is considered to be actuarially sound when the amount of money in the fund and the current level of premiums are sufficient (on the basis of assumptions on interest, mortality, medical, claims, and employee turnover) to meet the liabilities that have accrued and that are accruing on a current basis.
[7]
actuary Performance Management An insurance professional who performs the mathematical analysis necessary for setting insurance premium rates.
[3]
acute care Scheme Policy Medical treatment rendered to people whose illnesses or medical problems are short-term or do not require long-term continuing care.
[6]
acute disease Scheme Policy Illness characterized by a single episode of disease and constrained to a fairly brief period of time.
[7]
adjudication Factory The process of deciding whether the claim is valid, and what the reimbursement should be for the claim.
[2]Synonym: vetting
adjusted community rating (ACR) Scheme Policy A rating method under which a health plan or health insurance payer divides its members into classes or groups based on demographic factors such as geography, family composition, and age, and then charges all members of a class or group the same premium. The plan cannot consider the experience of a class, group, or tier in developing premium rates. Also known as modified community rating.
[3]
administration Factory The cost center that includes the overall management and administration of the health care institution, general patient accounting, communication systems, data processing, patient admissions, public relations, professional liability and non-property-related insurance, licenses and taxes, medical record activities, and procurement of supplies and equipment.
[7]
administrative costs Performance Management Medical costs related to utilization review, insurance marketing, medical underwriting, agents’ commissions, premium collection, claims processing, insurer profit, quality assurance programs, and risk management. Includes the costs assumed by a managed care plan for administrative services such as billing and overhead costs.
[7]
admission Scheme Policy The process of administrative registration for a patient in need of in-patient or outpatient medical care services.
[7]
admissions per 1,000 Performance Management An indicator calculated by taking the total number of inpatient or outpatient admissions from a specific group (e.g., employer group, HMO population at risk) for a specific period of time (usually 1 year), dividing it by the average number of covered members in that group during the same period, and multiplying the result by 1,000. This indicator can be calculated for behavioral health or any disease in the aggregate and by modality of treatment (e.g., inpatient, residential, and partial hospitalization).
[7]
admitting privilege Scheme Policy The right granted to a doctor to admit patients to a particular hospital.
[8]
adverse event Scheme Policy Any harm a patient suffers that is caused by factors other than the patient’s underlying condition. The most common of these is ADE = adverse drug events. [3]
adverse selection Scheme Policy The tendency of people who have a greater-than-average likelihood of loss to seek health care coverage to a greater extent than individuals who have an average or less-than-average likelihood of loss. In other words, people often wait to be sick before they seek health insurance coverage if the plan is not mandatory.
[3]Synonym: antiselection
age rating Scheme Policy Technique for adjusting insurance premiums or capitation payments according to the age of the insured.
[1]
ancillary services Scheme Policy Services, other than those provided by a physician or hospital, which are related to a patient’s care, such as laboratory work, x-rays, and anesthesia.
[9]
applicant Scheme Policy The person(s), employee, or entity applying for and signing the written application for a contract of health or managed care insurance or annuity, either on his or her own life or that of another.
[7]
asymmetrical information Scheme Policy Parties to a transaction have uneven access to relevant information that governs an informed choice. [13]
audit Performance Management The process of independently checking accounts and other records by auditors professionally trained and accredited for the purpose. It involves producing for the shareholders or trustees financial statements verifying the validity and accuracy of the companies’ accounts. Companies and institutions commonly engage in audit as an internal process within the organization to assist local management and to detect fraud or maladministration. Financial audit in health services has been an important tool in cost containment and efficiency studies; it is an essential requirement for ensuring public accountability.
[1]
authorization Scheme Policy A health plan’s system of approving payment of benefits for services that satisfy the plan’s requirements for coverage.
[3]
autonomy Scheme Policy An ethical principle which, when applied to managed care, states that health insurance payers and their providers have a duty to respect the right of their members to make decisions about the course of their lives.
[3]
average daily census (ADC) Performance Management The average number of patients in a health care facility per day. Derived by dividing the number of patient days for the year by the number of days the facility was open during the year.
[7]
average daily patient load Performance Management Number of hospital inpatients, excluding live births, during a reporting period or discharged the same day.
[7]

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balance billing Scheme Policy In case a provider has a contract with the insurance scheme but does not agree to avoid requiring the insured to pay for any monies not paid under the scheme, the insured can become liable for the difference (the balance) between what the scheme has paid and what the provider had originally charged.
[15]
balance sheet Performance Management The financial statement that shows a company’s financial status on a specified date. [3]
batch Factory A collection of health insurance claims or payments in or on a computer system or health care information technology network.
[7]
bed occupancy rate Performance Management A measure of the usage of beds during the reporting period that is derived by dividing the patient days in the reporting period by the bed days in the reporting period.
[7]Related to: length of stay
behavioral health care Scheme Policy The provision of mental health and chemical dependency (or substance abuse) services.
[3]
beneficiary Scheme Policy Any person eligible as either a subscriber or a dependent for a managed care service in accordance with a contract. Someone who is eligible for or receiving benefits under an insurance policy or plan.
[7]Synonym: enrollee
benefit Scheme Policy The amount payable by the insurance company to a claimant, assignee, or beneficiary when the insured suffers a loss. [8]
benefit cap Scheme Policy Total amount that a payer will reimburse for covered health care services during a specified period.
[9]
benefit design Scheme Policy The process a health insurance payer uses to determine which benefits or the level of benefits that will be offered to its members, the degree to which members will be expected to share the costs of such benefits, and how a member can access medical care through the health plan.
[3]
benefit plan Scheme Policy Included coverage, co-payments and options.
[2]
benefits package Scheme Policy Services covered by a health insurance plan and the financial terms of such coverage, including cost sharing and limitations on amounts of services.
[7]Synonym: insurance package
biometric identifier Scheme Policy An identifier based on some physical characteristic, such as fingerprints, DNA, or iris-scan.
[7]
birth rate Performance Management The number of births related to the total population in a given group during a given period of time.
[7]
brand-name drug Scheme Policy Prescription drugs marketed with a specific brand name by the company that manufactures it, usually the company which develops and patents it. [8]

Antonym: generic drug

budgeting Performance Management A process that includes creating a financial plan of action that an organization believes will help it to achieve its goals, given the organization’s forecast.
[3]

C

 

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cap Scheme Policy A limit placed on the amount that a health plan will pay in a specified period of time.
[7]
capitation Scheme Policy Payment system in which providers are paid a certain amount of money for each of their patients, regardless of the amount of care rendered. The capitation payments are generally pre-paid (i.e., paid in advance), with the amount depending on the age and gender (“age-sex banding”) and possibly other characteristics of the “roster” of patients who are assigned (“empaneled”) to that provider. If left unchecked, capitation can stimulate a perverse incentive known as “underutilization”.
[2]
care giver Scheme Policy One who renders medical care for a sick, injured, disabled, or elderly patient.
[7]Related to: provider
care management Scheme Policy A set of activities which assures that every person served by the treatment system has a single approved care (service) plan that is coordinated, not duplicative, and designed to assure cost effective and good outcomes. Care managers will oversee a patient’s journey through treatment.
[16]
care maps Scheme Policy Guidelines for suggested medical care and treatment.
[7]Related to: care plan, clinical pathway, treatment plan
care network Scheme Policy A family of primary care clinics, physicians, specialists, hospitals, and other health care professionals who provide a full range of health care services to members. Care networks decide whether members need referrals to see specialists within the care network.
[7]
care plan Scheme Policy A written plan for one’s health care.
[9]Synonym: treatment plan
carrier Scheme Policy A private organization, usually an insurance company, which finances healthcare.
[6]
carve-out Scheme Policy The separation of a medical service (or a group of services) from the basic set of benefits in some way.
[3]
case Scheme Policy An insurance-covered illness, accident, injury, disease, or situation.
[7]
case management Scheme Policy A process of identifying plan members with special health care needs, developing a health care strategy that meets those needs, and coordinating and monitoring care.
[3]
case manager Performance Management A nurse, doctor or social worker who arranges all services that are needed to give proper health care to a patient or group of patients.
[9]
case rate Scheme Policy Flat fee paid for a client’s treatment based on their diagnosis or presenting problem. For this fee the provider covers all of the services the client requires for a specific period of time. Also bundled rate, or flat fee-per-case. Very often used as an intervening step prior to capitation. In this model, the provider is accepting some significant risk, but does have considerable flexibility in how it meets the client’s needs.
[7]
case-fatality rate Performance Management The proportion of persons with a particular condition who die from that condition. The denominator is the number of incident cases; the numerator is the number of cause-specific deaths among those cases. [7]
catastrophic case Scheme Policy Any medical condition where total cost of treatment (regardless of payment source) is expected to exceed a designated amount for the care set by the insurer.
[7]
catastrophic coverage Scheme Policy Insurance coverage that is designed to protect the consumer from financial disaster in the case of a serious medical emergency. Because this type of coverage focuses primarily on the most expensive medical care, smaller expenses such as doctor visits or prescription drugs are usually not covered in catastrophic plans. Instead, these plans typically have high deductibles which must be met before the plan begins paying claims. Once the patient’s out-of-pocket spending reaches a specified maximum amount, the plan covers all expenses beyond that amount.
[10]
catastrophic illness Scheme Policy A very serious and costly health problem that could be life threatening or cause life-long disability. The cost of medical services alone for this type of serious condition could cause financial hardship.
[9]
catastrophic loss Scheme Policy Large loss that does not lend itself to prediction.
[7]
catchment area Scheme Policy The geographic area from which a health plan draws its patients.
[7]
cause of disease National Policy A factor (characteristic, behavior, event, etc.) that directly influences the occurrence of disease. A reduction of the factor in the population should lead to a reduction in the occurrence of disease.
[7]
centers of excellence Scheme Policy Hospitals that specialize in treating particular illnesses, or performing particular treatments, such as cancer or organ transplants. [9]
certification Factory The confirmation of certain characteristics of an object, person, or organization. This confirmation is often, but not always, provided by some form of external review, education, or assessment.
[4]
chronic care Scheme Policy Long-term care of individuals with long-standing, persistent diseases or conditions. It includes care specific to the problem as well as other measures to encourage self-care, to promote health, and to prevent loss of function.
[7]
chronic case Scheme Policy A patient with one or more medical conditions that persist for long periods of time or for the patient’s lifetime.
[3]
chronic disease Scheme Policy A medical problem that will not improve, lasts a lifetime, or recurs.
[6]Synonym: chronic illness
churning Performance Management The practice of a provider seeing a patient more often than is medically necessary, primarily to increase revenue through an increased number of visits.
[7]
claim Scheme Policy An itemized statement of health care services and their costs provided by a hospital, physician’s office or other provider facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.
[3]
claim exception Factory A report, notification, alert, event or alarm that occurs as the result of failed processing or adjudication of a claim. [18]
claim item Factory An entity, object or record that either is intended to represent, is a dependency for, or is pertaining to a specific claim.
[18]
claim load Performance Management The amount of benefits paid to the insureds in a period. Fluctuations in claim load in the short term are covered by contingency reserves and in the long run by contribution increases.
[13]
claims analysts / examiners Factory Employees in the claims administration department who consider all the information pertinent to a claim and make decisions about the health insurance payer’s payment of the claim.
[3]
claims arbitration Scheme Policy If a claim is denied, one can appeal. If the health plan offers arbitration, an independent third party reviews the dispute and recommends an outcome.
[10]
claims investigation Factory The process of obtaining all the information necessary to determine the appropriate amount to pay on a given claim.
[3]
claims management Factory The professional discipline that involves working with, in or on any aspect of planning, delivering, operating or supporting for one or more claim items or any and all solutions put in place to deal with such items
[18]
claims processing Factory The process of receiving, reviewing, adjudicating, and processing claims. [3]

Synonym: claims administration

clearinghouse Performance Management Shared information within systems abiding by security and confidentiality issues which provide maximum benefit to all stakeholders.
[2]
clinic Scheme Policy A facility for outpatient medical services.
[7]
clinical audit Performance Management Health review of medical care for quality improvement purposes.
[7]
clinical pathway Scheme Policy Multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or visit (homecare). Outcomes are tied to specific interventions.
[4]Related to: care maps, care plan, treatment plan
clinical practice guidelines Scheme Policy Reports written by experts who have carefully studied whether a treatment works and which patients are most likely to be helped by it.
[9]
clinical practice management Scheme Policy The development and implementation of parameters for the delivery of health care services to plan members.
[3]
clinical protocols Scheme Policy Guidelines for treating specific injuries and conditions.
[7]
clinical status Performance Management A type of outcome measure that relates to biological health outcomes.
[3]
closed access Scheme Policy A provision which specifies that plan members must obtain medical services only from network providers through a primary care physician.
[3]
closed formulary Scheme Policy The provision that only those drugs on a preferred list will be covered. [3]
code set Factory A set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes.
[7]
coding errors Factory Documentation errors in which a treatment is miscoded or the codes used to describe procedures do not match those used to identify the diagnosis.
[3]
coinsurance Scheme Policy Spreads a risk too great for a single insurer over several companies that together act as coinsurers.
[13]
co-insurance Scheme Policy Money that an individual is required to pay for services, after a deductible has been paid, often specified as a percentage.
[8]
collection rate Performance Management The proportion of possible subscriptions from members that the insurer collects. It may be used as a measure of an insurer’s efficiency/commercial orientation.
[13]Synonym: compliance rate
community Scheme Policy A specific group of people, often living in a defined geographical area, who share a common culture, values and norms, are arranged in a social structure according to relationships which the community has developed over a period of time. Members of a community gain their personal and social identity by sharing common beliefs, values and norms which have been developed by the community in the past and may be modified in the future. They exhibit some awareness of their identity as a group, and share common needs and a commitment to meeting them.
[1]
community financing scheme Scheme Policy See: community-based health insurance (CBHI)
community rating Scheme Policy A rating method that sets premiums for financing medical care according to the health plan’s expected costs of providing medical benefits to the community as a whole rather than to any sub-group within the community. Both low-risk and high-risk classes are factored into community rating, which spreads the expected medical care costs across the entire community.
[3]
community rating by class (CRC) Scheme Policy The process of determining premium rates in which a health insurance payer categorizes its members into classes or groups based on demographic factors, industry characteristics, or experience and charges the same premium to all members of the same class or group.
[3]
community-based health insurance (CBHI) Scheme Policy In CBHI, communities operate and control the financing of their health care typically through locally-based prepayment schemes. Under these schemes financing and delivery of primary care can be separated or integrated, but higher level care is usually purchased by the scheme. Affiliation is based on community membership, with strong involvement of the community the management of the system.
[11]
compensation Scheme Policy Benefit payout.
[13]
complaint Scheme Policy A health plan member’s expression that his expectations regarding the product or the services associated with the product have not been met.
[3]
compliance Scheme Policy Payment of contribution owed by members.
[13]
compliance gap Performance Management Difference between contributions due and contributions collected. [13]
concurrent review Scheme Policy Monitoring the medical treatment and progress toward recovery, once a patient is admitted to a hospital, to assure timely delivery of services and to confirm the necessity of continued inpatient care. This monitoring is under the direction of medical professionals.
[9]
confidentiality Scheme Policy One of the aspects of the responsiveness of health systems whereby privacy in the context of privileged communication (such as patient-doctor consultations) and medical records is safeguarded.
[1]
contingency reserves Scheme Policy Funds held by the insurer that are in excess of expected benefit payouts in order to cover unexpected events (contingencies) that cause fluctuations in benefit payouts.
[13]Synonym: equalization reserves
contract Scheme Policy A legal agreement between a payer and a subscribing group or individual that specifies rates, performance covenants, the relationship among the parties, schedule of benefits, and other pertinent conditions. The contract usually is limited to a 12-month period and is subject to renewal thereafter.
[7]
contract management system Factory An information system that incorporates membership data and provider reimbursement arrangements and analyzes transactions according to contract rules.
[3]
contract year Scheme Policy The period of time from the effective date of the contract to the expiration date of the contract. A contract year is typically 12 months long, but not necessarily from January 1 through December 31.
[9]
contracted provider Scheme Policy Any hospital, skilled-nursing facility, extended-care facility, individual, organization, or licensed agency that has a contractual arrangement with an insurer for the provision of services under an insurance contract. [7]
contributions Scheme Policy When the insurance scheme is not mandatory, premiums paid for by the insured are called contributions.
[15]
coordination of benefits (COB) Scheme Policy A provision in the contract that applies when a person is covered under more than one health insurance plan. It requires that payment of benefits be coordinated by all plans to eliminate over-insurance or duplication of benefits.
[9]
copayment Scheme Policy Money that an individual is required to pay for services, usually specified as an absolute amount: a predetermined (flat) fee that an individual pays for health care service, in addition to what the insurance covers.
[8]
cost containment Performance Management The method of preventing health care costs from increasing beyond a set level by controlling or reducing inefficiency and waste in the healthcare system.
[6]
cost effectiveness Performance Management The efficacy of a program in achieving given intervention outcomes in relation to the program costs.
[7]
cost of illness Scheme Policy The personal cost of acute or chronic disease. The cost to the patient may be an economic, social, or psychological cost or personal loss to self, family, or immediate community. The cost of illness may be reflected in absenteeism, productivity, response to treatment, peace of mind, quality of life, etc.
[5]
cost sharing Scheme Policy This occurs when the users of a healthcare plan share in the cost of medical care. Deductibles, co-insurance, and co-payments are examples of cost sharing. [9]
cost shifting Scheme Policy The practice of charging more for services provided to paying patients or third-party payers to compensate for lost revenue resulting from services provided free or at a significantly reduced cost to other patients.
[3]
coverage Scheme Policy A person’s health care costs are paid by their insurance or by the government.
[6]
covered benefits Scheme Policy Health services or items that are included in the health plan and that are partially or fully paid by the health plan.
[9]Synonym: covered services
covered person Scheme Policy A person who both meets the eligibility requirements of the contract and is enrolled for coverage under the contract.
[7]
credentialing Scheme Policy The review and verification process used to determine the current clinical competence of a provider and whether the provider meets the health insurance payer’s preestablished criteria for participation in the network.
[3]
cure provision Scheme Policy A provider contract clause which specifies a time period (usually 60-90 days) for a party that breaches the contract to remedy the problem and avoid termination of the contract.
[3]

D

 

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data dictionary Factory Defines what information is contained in a database, how the information will be used, and how the items in the database relate to each other. In the health sector, this dictionary is known as the Health Data Dictionary. [2]
data model Factory Defines how data formats fit together to create a healthcare system.
[2]
date of issue Scheme Policy The date that an initial health care insurance contract premium is received and the contract owner information is approved.
[7]
date of policy Scheme Policy The date appearing on the front page of a health insurance policy indicating when the policy went into effect.
[7]
death-to-case ratio Performance Management The number of deaths attributed to a particular disease during a specified time period divided by the number of new cases of that disease identified during the same time period.
[7]
deductible Scheme Policy The amount an individual must pay for healthcare expenses before insurance covers the costs.
[8]
demand management Scheme Policy Promoting and reducing the need for medical services through such strategies as prevention, risk identification, risk management, and empowering consumers and providers to make appropriate choices about care through education and informed decision-making tools.
[7]
demand rationing Scheme Policy Barrier to health insurance access as a result of financial constraints. [7]
denial of a claim Scheme Policy The refusal of an insurance company or carrier to honor a request by an individual (or his or her provider) to pay for health care services obtained from a health care professional.
[8]Synonym: rejected claim
dependency ratio Performance Management An indicator used in population studies to measure the portion of the population which is economically dependent on active age group. It is calculated as the sum of 0-14 year olds and over 60 or 65 year olds, depending on the working age limit considered, divided by the number of people aged between 15 and 59 or 64, respectively. For the purpose of the World Health Report, it is calculated as the sum of 0-14 year olds and over 65 year olds divided by the number of people aged between 15 and 64.
[1]
dependent Scheme Policy The lawful spouse and each unmarried child who is not employed on a regular full-time basis and who is dependent upon the declaring individual for support and maintenance. The term includes stepchildren, adopted children, and foster children. One who relies on a spouse, parent, grandparent, legal guardian, or one with whom they reside for health care insurance. The definition of dependent is subject to differing conditions and limitations between health care plans.
[7]
diagnosis Scheme Policy The specific or provisional name of a mental or physical disease, illness, disability, condition, or injury.
[7]
diagnostic admission Scheme Policy Entrance into a health care facility for tests and explorative interventions to establish a cause of illness. [7]
diagnostic and treatment codes Factory Special codes that consist of a brief, specific description of each diagnosis or treatment and a number used to identify each diagnosis and treatment.
[3]
diagnostic-related group (DRG) Factory A system for classifying hospital stays according to the diagnosis of the medical problem being treated for the purposes of payment.
[6]
direct access Scheme Policy The ability to see a doctor or receive a medical service without referral from a primary care physician.
[6]
direct patient expenditure Performance Management Expenditure that relates directly to the individual care of a patient such as drugs, specific treatments received, and food.
[1]
disability-adjusted life expectancy Performance Management The number of healthy years of life that can be expected on average in a given population. It is generally calculated at birth, but estimates can also be prepared at other ages. Healthy life expectancy has the advantage of capturing all causes of disability across a population and relating them to life expectancy defined by mortality.
[1]
disability-adjusted life years (DALYS) Performance Management The number of healthy years of life lost due to premature death and disability.
[1]
discharge Scheme Policy A patient who was formally admitted to a hospital as an inpatient for observation, diagnosis, or treatment, with the expectation of remaining overnight or longer, and who is discharged under one of the following circumstances: (a) is formally discharged from care of the hospital and leaves the hospital; (b) transfers within the hospital from one type of care to another type of care; or (c) has expired. [7]
discharge planning Scheme Policy A process the health insurance payer uses to help determine what activities must occur before the patient is ready for discharge and the most efficient way to conduct those activities.
[3]
disease management Scheme Policy Programs for people who have chronic illnesses, such as asthma or diabetes, that try to encourage them to have a healthy lifestyle, to take medications as prescribed, and that coordinate care.
[6]Synonym: disease state management
disenrollment Scheme Policy Ending a person’s healthcare coverage with a health plan.
[9]
drug formulary Scheme Policy A list of prescription drugs that are preferred by the health plan.
[10]Synonym: formulary
drug utilization Performance Management Drug prescription and usage patterns. [5]
drugs Scheme Policy Substances that, when taken into the living organism, may modify one or more of its functions.
[12]Synonym: pharmaceuticals when vended in the health care sector

E

 

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edits Factory Criteria that if unmet will cause an automated claims processing system to “kick out” a claim for further investigation.
[3]
effective date Scheme Policy The date health insurance coverage begins.
[9]
effectiveness Performance Management The contribution which a program makes to individuals’ utility or welfare, normally through better health, but not necessarily solely through better health.
[5]Synonym: efficacy
efficiency Performance Management Avoiding waste, including waste of equipment, supplies, ideas, and energy.
[2]
elective procedure Scheme Policy A health care procedure that is not an emergency and that the patient and doctor plan in advance.
[6]
electronic claim Factory The digital representation of a medical claim which is sent from provider to payer via a digital means rather than on paper.
[7]
electronic medical record (EMR) Factory A computerized record of a patient’s clinical, demographic, and administrative data.
[3]Synonym: computer-based patient record (CPR), electronic health record, patient health record
eligibility Scheme Policy Validity for participation.
[4]
eligibility checking Factory The ability of the health management information system to verify an individual’s coverage; as simple as verifying coverage or as complex as noting amount of coverage, type of insurance, covered services, co-payments, deductibles (totals and remaining balances), etc.
[2]Synonym: eligibility inquiry
eligibility requirements Scheme Policy Rules in group life, health, or disability insurance to determine which employees may enter into the plan.
[7]Synonym: eligibility rules
emergency Scheme Policy Sudden unexpected onset of illness or injury that requires the immediate care and attention of a qualified physician, and which, if not treated immediately, would jeopardize or impair the health of the member, as determined by the payer’s medical staff.
[7]
emergency care Scheme Policy Medical care rendered for a condition for which the patient believes acute life-threatening attention is required.
[7]
empaneling Scheme Policy Assigning patients to providers.
[2]
empowerment for health Scheme Policy A process through which people gain greater control over decisions and actions affecting their health. [1]
encounter Scheme Policy One health care visit of any type by an enrollee to a provider of care or services.
[3]
encounter date Scheme Policy The date on which health care services are provided to a covered person. The encounter date, not the date on which the insurance company pays a healthcare claim, is the critical date in determining health insurance benefits. For example, a health insurance company will not pay a claim for health care services incurred prior to the effective date of the health insurance coverage.
[9]Synonym: date of service (DOS)
encounter report Scheme Policy A report that supplies management information about services provided each time a patient visits a provider.
[3]
endorsement Scheme Policy Amendment to the policy used to add or delete coverage.
[7]
enrollment Scheme Policy The number of members in an HMO or health insurance plan. The number of members assigned to a physician or medical group providing care under contract with an HMO. Also, can be the process by which a health plan signs up individuals or groups as subscribers.
[7]
enterprise architecture (EA) Factory An enterprise architecture (EA) is a description of the structure of an enterprise, which comprises enterprise components (business entities), the externally visible properties of those components, and the relationships (e.g. the behavior) between them. Enterprise architecture describes the terminology, the composition of enterprise components, and their relationships with the external environment, and the guiding principles for the requirement (analysis), design, and evolution of an enterprise. This description is comprehensive, including enterprise goals, business process, roles, organizational structures, organizational behaviors, business information, software applications and computer systems.
[4]
equitable Performance Management Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. [2]
equity Performance Management Being fair or equal; equality of status in respect to some identifiable and controllable quality of importance, such as health, access to services, or exposure to risk. Equity in health implies that ideally everyone should have a fair opportunity to attain their full health potential and more pragmatically that no one should be disadvantaged from achieving this potential. People’s needs guide the distribution of opportunities for well-being.
[1]
error rate Factory A measure of the accuracy of information given and transactions processed.
[3]
exclusion Scheme Policy A provision within a health insurance policy that eliminates coverage for certain acts, property, types of damage, or locations.
[8]
exclusion period Scheme Policy A period of time when an insurance company can delay coverage of a preexisting condition. Sometimes this is called a preexisting condition waiting period.
[9]
exclusive provider organization (EPO) Scheme Policy A healthcare benefit arrangement that is similar to a preferred provider organization in administration, structure, and operation but which does not cover out-of-network care.
[3]
expiration date Scheme Policy The date on a health insurance policy that indicates when coverage ends.
[7]
explanation of benefits (EOB) Scheme Policy A statement of coverage that lists any health services that have been provided as well as the amount billed and payment made by the health plan for those services. [7]

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false claim Performance Management Incorrect or fraudulent medical insurance claim.
[7]
fee for service Scheme Policy The health care provider is paid a fee based on what services the provider rendered.
[2]
fee schedule Scheme Policy A complete listing of fees used by health plans to pay doctors or other providers.
[9]Synonym: provider rate schedule
fiduciary management Scheme Policy Fiduciary management is an approach to asset management that involves an asset owner appointing a third party to manage the total assets of the asset owner on an integrated basis through a combination of advisory and delegated investment services, with a view to achieving the asset owner’s overall investment objectives.
[4]
financial limit Scheme Policy A limit on the amount of benefits paid out for a particular covered expense as disclosed on the certificate of insurance.
[8]
financial management Performance Management The process of managing a health insurance payer’s financial resources including management decisions concerning accounting and financial reporting, forecasting, and budgeting.
[3]
formal sector National Policy The part of the economy/society that is registered with authorities and that is subject to regulations and standards. [13]
fraud Performance Management A deception that could result in unnecessarily paying for medical services. For example, if a provider files a claim for a service that was not provided.
[7]
fully funded plan Scheme Policy A health plan under which an insurer or health insurance payer bears the financial responsibility of guaranteeing claim payments and paying for all incurred covered benefits and administration costs.
[3]

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gatekeeper Scheme Policy The person in a health insurance payer organization, often a primary care provider (PCP), who controls a patient’s access to health care services and whose approval is required for referrals to other services or other specialists.
[6]
general government expenditure on health National Policy The sum of outlays for health maintenance, restoration or enhancement paid for in cash or supplied in kind by government entities, such as the Ministry of Health, other ministries, parastatal organizations, social security agents, (without double-counting the government transfers to social security and extra-budgetary funds). Includes transfer payments to households to offset medical care costs and extra-budgetary funds to finance health services and goods. The revenue base of these entities may comprise multiple sources, including external funds.
[14]
general practice Scheme Policy Physicians without specialty training who provide a wide range of primary health care services to patients.
[6]
general practitioner Scheme Policy A family practitioner that provides medical care to people of all ages.
[7]
generic drug Scheme Policy Once a company’s patent on a brand-name prescription drug has expired, other drug companies are allowed to sell the same drug under a generic label. Generic drugs are less expensive. [8]

Antonym: brand-name drug

generic substitution Scheme Policy The dispensing of a drug that is the generic equivalent of a drug listed on a formulary of a pharmacy benefit management plan.
[3]
governance National Policy The exercise of political, economic, and administrative authority in the management of a country’s affairs at all levels. It is a neutral concept comprising the complex mechanisms, processes, relationships and institutions through which citizens and groups articulate their interests, exercise their rights and obligations, and mediate their differences.
[1]
group health insurance Scheme Policy Coverage through an employer or other entity that covers all individuals in the group.
[8]
guaranteed issue Scheme Policy The requirement that an insurance plan accept everyone who applies for coverage and guarantee the renewal of that coverage as long as the covered person pays the policy premium.
[6]

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health National Policy A state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity. Health is a resource for everyday life, not the object of living. It is a positive concept emphasizing social and personal resources as well as physical capabilities. [1]
health care costs National Policy The societal cost of providing services related to the delivery of health care.
[5]
health care delivery National Policy One of the functions of the health system, which deals with the medical and therapeutic measures intended to preserve or improve the health condition of a patient.
[1]
health equity National Policy Ensuring that the same quality of health is provided to all regardless of economic, social, cultural, geographical, or other differences; reducing gaps in health outcomes.
[2]
health expenditures Performance Management The amounts spent by individuals, groups, nations, or private or public organizations for total healthcare and/or its various components. These amounts may or may not be equivalent to the actual costs (healthcare costs) and may or may not be shared among the patient, insurers, and/or employers.
[5]
health gain Performance Management An increase in the measured health of an individual or population, including length and quality of life.
[1]
health indicator Performance Management A measure that reflects, or indicates, the state of health of persons in a defined population (e.g., the infant mortality rate).
[7]
health inequalities National Policy The gap in health status and in access to health services between different social classes and ethnic groups and between populations in different geographical areas. [5]
health insurance Scheme Policy Financial protection against the healthcare costs caused by treating disease or accidental injury.
[6]
health insurance payer Scheme Policy Entity which collects, contracts for, and pays for health services from “providers.”
[2]
health maintenance organization (HMO) Scheme Policy A prepaid health plan delivering comprehensive care to members through designated providers, having a fixed monthly payment for health care services, and requiring members to be in a plan for a specified period of time.
[5]
health management information system (HMIS) Factory The use of electronic information and communications technologies to provide and facilitate healthcare and health related services, improving healthcare processes.
[2]
health outcome Performance Management The result of a healthcare intervention weighted by a value assigned to that result.
[5]
health plan Scheme Policy A generic term to refer to a specific benefit package offered by an insurer.
[7]
health planning Scheme Policy Planning for needed health and/or welfare services and facilities. [5]

Synonym: health service planning

health policy National Policy A set of decisions or commitments to pursue courses of action aimed at achieving defined goals for improving health. A formal statement or procedure within institutions (notably government) which defines priorities and the parameters for action in response to health needs, available resources, and other political pressures.
[1]Synonym: policy, regulatory
health promotion programs National Policy Preventive care programs designed to educate and motivate members to prevent illness and injury and to promote good health through lifestyle choices, such as smoking cessation and dietary changes.
[3]Synonym: wellness programs
health risk assessment Scheme Policy A process by which a health insurance payer uses information about a plan member’s health status, personal and family health history, and health-related behaviors to predict the member’s likelihood of experiencing specific illnesses or injuries.
[3]Synonym: health risk appraisal
health sector National Policy The health sector consists of organized public and private health services (including health promotion, disease prevention, diagnostic, treatment and care services), the policies and activities of health departments and ministries, health related nongovernment organizations and community groups, and professional associations.
[1]
health service National Policy Any service which can contribute to improved health or the diagnosis, treatment, and rehabilitation of sick people and not necessarily limited to medical or healthcare services. Health services are often formally organized as a system of established institutions and organizations to supply services to respond to the needs and demands of the population within a defined financial and regulatory framework. Health services can include health education; health promotion; and environmental services such as housing, sanitation, etc., which have a known health benefit.
[1]
health status Performance Management A general term for the state of health of an individual, group, or population at a particular point in time measured against defined standards.
[1]
health system National Policy The people, institutions and resources arranged together in accordance with established policies to improve the health of the population they serve, while responding to people’s legitimate expectations and protecting them against the cost of ill-health through a variety of activities whose primary intent is to improve health. Set of elements and their relations in a complex whole, designed to serve the health needs of the population. Health systems fulfill three main functions: healthcare delivery, fair treatment to all, and meeting non-health expectations of the population. These functions are performed in the pursuit of three goals: health, responsiveness and fair financing.
[1]
healthcare National Policy The diagnosis, treatment and prevention of disease, illness, injury, and other physical and mental impairments in humans. Healthcare is delivered by practitioners in medicine, chiropractic, dentistry, nursing, pharmacy, allied health and other care providers.
[4]
healthcare rationing National Policy Planning for the equitable allocation, apportionment, or distribution of available health resources.
[5]
healthcare sector National Policy Economic sector concerned with the provision, distribution, and consumption of health care services and related products. [5]
healthy years equivalents (HYE) Performance Management The number of years of perfect health that are considered equivalent to (i.e., have the same utility as) the remaining years of life in their respective health states.
[5]
high-cost case Scheme Policy A patient whose condition requires large financial expenditures or significant human and technological resources.
[3]
high-risk case Scheme Policy A patient who has a complex or catastrophic illness or injury or who requires extensive medical interventions or treatment plans.
[3]
home health care Scheme Policy Services given at home to aged, disabled, sick, or convalescent individuals not needing institutional care. The most common types of home care are visiting nurse services and speech, physical, occupational, and rehabilitation therapy. These services are provided by home health agencies, hospitals, or other community organizations.
[9]
hospice care Scheme Policy Care for the terminally ill and their families in the home or a non-hospital setting that emphasizes alleviating pain rather than a medical cure.
[9]
hospital Scheme Policy Any institution duly licensed, certified, and operated as a hospital. The term hospital does not include a convalescent facility, nursing home, or any institution or part thereof which is used principally as a convalescence facility, rest facility, nursing facility, or facility for the aged. An institution for the care and treatment of ill, injured, infirm, mentally abnormal, or deformed persons, with organized facilities for diagnosis and surgery and providing 24-hr nursing service and medical supervision.
[7]
hospital costs Performance Management The expenses incurred by a hospital in providing care. The hospital costs attributed to a particular patient care episode include the direct costs plus an appropriate proportion of the overhead for administration, personnel, building maintenance, equipment, etc. [5]
hospitalist Scheme Policy Physician who spends a substantial amount of their time in a hospital setting where they accept admissions to their inpatient services from local primary care providers.
[3]
human capital National Policy Human skills and capabilities generated by investments in education and health.
[1]

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identification card Scheme Policy A card given to each person covered under a health plan that identifies an insured as being eligible for benefits.
[7]
illness Scheme Policy Any bodily disorder, bodily injury, disease, or mental health condition, including pregnancy and complications of pregnancy.
[7]
immunization program Scheme Policy Preventive care program designed to monitor and promote the administration of vaccines to guard against childhood illnesses, such as chicken pox, mumps, and measles, and adult illnesses, such as pneumonia and influenza.
[3]
inception date Scheme Policy Date that a health care insurance policy becomes effective.
[7]
incidence Performance Management The number of cases of disease, infection, or some other event having their onset during a prescribed period of time in relation to the unit of population in which they occur. It usually refers only to the number of new cases, particularly of chronic diseases. [7]
indemnity health plan Scheme Policy With indemnity plans, the individual pays a predetermined percentage of the cost of health care services, and the health plan pays the other percentage. For example, an individual might pay 20% for services and the insurance company pays 80%. The fees for services are defined by the health care providers and vary from physician to physician and hospital to hospital.
[9]
indicator Performance Management A measure of a specific component of a health improvement strategy. An indicator can reflect an activity implemented to address a particular health issue, such as the number of children aged 2 years who have received all appropriate immunizations, or it might reflect outcomes from activities already implemented, such as a decline in the number of cases of childhood measles in any given year.
[7]
indigent care National Policy Care provided at no cost to people who do not have health insurance and are not covered by any public program.
[6]
indirect patient expenditure Performance Management The items of expenditure that cannot be attributed to the care of individual patients such as lighting, heating, capital equipment, support staff, and services.
[1]
individual health insurance Scheme Policy Health insurance coverage on an individual, not group, basis. The premium is usually higher for an individual health insurance plan than for a group policy, but the individual may not qualify for a group plan.
[8]
inequality in health Performance Management Disparities in health across individuals in the population.
[1]
informal sector National Policy The part of the society/economy that is not registered with authorities and, whether with legal exclusion or without it (de jure or de facto), is not subject to public regulation and does not benefit from public services or goods. For example, support given by a family, friends, and members of a community in times of loss or illness effectively forms an informal risk-protection mechanism. Despite the presumption that such care is voluntarily given, in some cases (for example, providing care to foster children), payment may in fact be given. [13]
information asymmetry Scheme Policy The difference in the amount of information available to the various parties to a transaction which does not place them on equal footing to negotiate.
[1]Synonym: moral hazard
information management Factory The combination of systems, processes, and technology that a health insurance payer uses to provide the company’s information users with the information they need to carry out their job responsibilities.
[3]
information system Factory An interactive combination of people, computer hardware and software, communications devices, and procedures designed to provide a continuous flow of information to the people who need information to make decisions or perform activities.
[3]
information technology Factory The wide range of electronic devices and tools used to acquire, record, store, transfer or transform data or information.
[3]
injury Scheme Policy Bodily damage sustained by accident. [7]
inpatient Scheme Policy A person who has been admitted to a hospital or other health facility for a period of at least 24 hours.
[6]
inpatient care Scheme Policy Health care received while a patient stays overnight in a hospital.
[9]
insurability Scheme Policy A risk is insurable if it is random, and there is a party willing to accept the risk for an agreed premium and another party is prepared to pay that premium (this means it is solvable). This situation implies that the probability is known, it is free of moral hazard and adverse selection problems, that it is a legal proposition, and that the premium is affordable. Practical problems associated with information availability may render otherwise insurable risks uninsurable.
[13]
insurance company Scheme Policy A corporation, association, or fraternal benefit society engaged primarily in the business of furnishing insurance protection to the public. Accepts various perils, hazards, and risks of an insured in return for premium payments, and in return, promises to indemnify for losses, provide other pecuniary benefits, or render a service.
[7]
insurance policy Scheme Policy The insurance agreement or contract.
[9]
insurance policy holder Scheme Policy The insured person named on the insurance policy.
[9]
insurance policy year Scheme Policy The 12-month period beginning with the effective date or renewal date of the policy. [9]
insurance program Scheme Policy A unified life or health insurance plan that coordinates the needs, policies, and settlement options available to carry out the aims and objectives of a client.
[7]
insurance threshold Scheme Policy Insurers typically request that the insured pay the first part of any claim. This cost sharing is a form of deductible, used to simplify administration by reducing the number of small claims.
[13]
insured Scheme Policy The party or plan member to an insurance contract, covering health or other insurance, to whom, or on behalf of whom, the insurer agrees to indemnify for losses, provide benefits, or render services. The individual or group covered by the contract of insurance.
[7]
insurer Scheme Policy The company underwriting the insurance and assuming the risk.
The party to an insurance contract that undertakes to indemnify for losses, provide other pecuniary benefits, or render services.
[7]
integrated delivery system (IDS) Scheme Policy A network of hospitals, physicians, and other medical services, along with an HMO or insurance plan, formed to cost-effectively provide a population with a full continuum of care (i.e., from prevention through check-ups, tests, surgery, rehabilitation, long-term, and home care) that is accountable for costs, quality of care, and customer satisfaction.
[7]
integrated provider (IP) Scheme Policy A group of providers that offer comprehensive and coordinated care and usually provides a range of medical care facilities and service plans including hospitals, group practices, a health plan and other related health care services.
[6]
intensive care Scheme Policy Medical care for complex illness and to patients who are unable to maintain vital functions. [7]
international classification of primary care (ICPC) Factory A classification method for primary care encounters which allows for the classification of the patient’s reason for encounter (RFE), the problems/diagnosis managed, primary care interventions, and the ordering of the data of the primary care session in an episode of care structure. It is being developed by the International Classification Committee (WICC). ICPC was first published in 1987 by Oxford University Press (ICPC-1) and a revision and inclusion of criteria and definitions was published in 1998 (ICPC-2).
[4]
international statistical classification of diseases and related health problems (ICD) Factory A coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases as classified by the World Health Organization.
[7]

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key performance indicator (KPI) Performance Management A key performance indicator is a measure of performance. KPIs are commonly used by an organization to evaluate its success or the success of a particular or activity in which it is engaged. KPIs are ways to periodically assess the performances of organizations, business units, and their division, departments and employees. Accordingly, KPIs are most commonly defined in a way that is understandable, meaningful, and measurable. KPI, in practical terms and for strategic development, are objectives to be targeted that will add the most value to the business.
[4]Synonym: key success indicator, performance indicator

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lapse Scheme Policy Termination of insurance for non-payment of premium.
[9]
length of stay (LOS) Scheme Policy The amount of time an individual stays in a hospital or inpatient facility.
[8]
length of stay guidelines Scheme Policy A utilization review resource that establishes an average inpatient length of stay based on a patient’s diagnosis, the severity of the patient’s condition, and the type of services and procedures prescribed for the patient’s care.
[3]
licensure National Policy The granting of a license, which gives “permission to practice”. In general, licenses are used to regulate activities that are deemed to be dangerous or a threat to the person or the public or which involve a high level of specialized skill. [4]
life expectancy Performance Management The number of years of life that can be expected on average in a given population.
[1]
lifetime maximum payments Scheme Policy A cap on the benefits paid for the duration of a health insurance policy. When a policy has a lifetime limit of X, the insurer agrees to cover up to amount X in covered services over the life of the policy. Once the maximum amount X is reached, no additional benefits are payable.
[9]
limitations Scheme Policy A limit on the amount of services that may be provided. It may be the maximum cost or number of days that a service or treatment is covered.
[6]
limited policy Scheme Policy A policy that covers only specified accidents or sicknesses.
[9]
limited service hospital Scheme Policy A hospital, often located in a rural area, which provides a limited set of medical and surgical services.
[6]
line item Factory Service or item-specific detail of claim.
[7]
linkage National Policy Degree of vertical and horizontal fragmentation or integration in the healthcare system. [2]
load Performance Management The cost of insurance (administration, finance, and so on) as distinct from payouts (benefits). Efficient companies have a low load relative to benefits.
[13]
long-term care Scheme Policy Health care, personal care, and social services provided to people who have a chronic illness or disability and do not have full functional capacity. This care can take place in an institution or at home, on a long-term basis.
[6]
loss ratio Performance Management The ratio of incurred claims to collected premium.
[13]

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managed care Performance Management The integration of both the financing and delivery of health care within a system that seeks to manage the accessibility, cost, and quality of that care.
[3]
managed care organization (MCO) Performance Management Any entity that utilizes certain concepts or techniques to manage the accessibility, cost, and quality of healthcare.
[3]
manual rating Scheme Policy A rating method under which a health plan uses the plan’s average experience with all groups—and sometimes the experience of other health plans—rather than a particular group’s experience to calculate the group’s premium. A health insurance payer often lists manual rates in an underwriting or rating manual.
[3]
marketing Scheme Policy The process of planning and executing the conception, pricing, promotion, and distribution of ideas, goods, and services to create exchanges that satisfy individual and organizational objectives. [3]
master policy Scheme Policy The group insurance policy that explains coverage to all members of the group.
[9]
medical error Performance Management A mistake that occurs when a planned treatment or procedure is delivered incorrectly or when a wrong treatment or procedure is delivered.
[3]
medical ethics Scheme Policy The principles and values that guide the actions of an individual or population when faced with questions of right and wrong.
[3]
medical loss ratio Performance Management The relationship of medical insurance premiums paid out for claims.
[7]
medical necessity Scheme Policy Medical information justifying that the service rendered or item provided is reasonable and appropriate for the diagnosis or treatment of a medical condition or illness.
[9]
medically necessary Scheme Policy Many insurance policies will pay only for treatment that is deemed “medically necessary” to restore a person’s health. For instance, many health insurance policies will not cover routine physical exams or plastic surgery for cosmetic purposes.
[9]
member Scheme Policy This term is a close synonym of insured, however it usually connotes benefits in a particular form of insurance scheme. This word became popular with the HMO (Health Maintenance Organization) movement in the USA and is now used in other countries to represent membership in an integrated health services delivery scheme. An example is when a payer has its own health care delivery system. [15]
member services Scheme Policy The broad range of activities that a health insurance payer and its employees undertake to support the delivery of the promised benefits to members and to keep members satisfied with the company.
[3]
microinsurance Scheme Policy A mechanism for pooling a whole community’s risks and resources to protect all its participating members against the financial consequences of mutually determined health risks.
[13]
morbidity Performance Management A measure of disease incidence or prevalence in a given population, location, or other grouping of interest.
[7]
morbidity rate Performance Management The ratio of the incidence of sickness to the number of well persons in a given group of people over a given period of time.
[7]
mortality Performance Management A measure of deaths in a given population, location, or other grouping of interest.
[7]
mortality rate Performance Management The ratio of the number of deaths in a given group in a year’s time to the total number in the group exposed to the risk of death.
[7]

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national health accounts National Policy Information, usually in the form of indicators, a country may collect on its health expenditures. Indicators may include total health expenditure, public expenditure, private expenditure, out-of-pocket expenditure, tax-funded and other public expenditure, social security expenditure, or public expenditure on health. [1]
national health expenditures National Policy Total spending on health services, prescription, and over-the-counter drugs and products, nursing home care, insurance costs, public health spending, and health research and construction.
[7]
network Scheme Policy A group of doctors, hospitals, and other health care providers contracted to provide services to insurance companies’ customers for less than their usual fees. Provider networks can cover a large geographic market or a wide range of health care services. Insured individuals typically pay less for using a network provider.
[8]
network provider Scheme Policy Providers or health care facilities that are part of a health plan’s network of providers with which it has negotiated a discount. Insured individuals usually pay less when using an in-network provider because those networks provide services at a lower cost to the insurance companies with which they have contracts.
[8]
non-participating provider Scheme Policy A health care provider who is not part of a health plan. Usually patients must pay their own health care costs to see a non-participating provider.
[6]
nurse practitioner Scheme Policy A nurse specialist who provides primary and/or specialty care to patients.
[6]
nursery Scheme Policy A hospital perinatal unit for normal newborns that includes incubators for nondistressed, low-birth-weight babies.
[7]
nursing home Scheme Policy A residence facility that provides room, board, and help in the activities of daily living. [7]

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occupational health Scheme Policy Activities undertaken to protect and promote the health and safety of employees in the workplace, including minimizing exposure to hazardous substances, evaluating work practices, and environments to reduce injury, and reducing or eliminating other health threats.
[7]
occurrence Scheme Policy An accident or sickness that results in an insured loss.
[7]
open access Scheme Policy A provision that specifies that plan members may self-refer to a specialist, either in the network or out of the network, at full benefit or at a reduced benefit without first obtaining a referral from a primary care provider.
[3]
open formulary Scheme Policy The provision that drugs on the preferred list and those not on the preferred list will both be covered.
[3]
open panel Scheme Policy The covered person is allowed to get non-emergency covered services from a specialist without getting a referral from the primary care physician or gatekeeper.
[6]
outcomes measures Performance Management Health care quality indicators that gauge the extent to which health care services succeed in improving or maintaining satisfaction and patient health.
[3]
out-of-network provider Scheme Policy A provider which has not been contracted with the insurance company for reimbursement at a negotiated rate. [10]
out-of-pocket (OOP) payment Performance Management Fee paid by the consumer of health services directly to the provider at the time of delivery.
[1]
outpatient Scheme Policy An individual (patient) who receives health care services on an outpatient basis, meaning they do not stay overnight in a hospital or inpatient facility.
[8]
outpatient care Scheme Policy Treatment that is provided to a patient who is able to return home after care without an overnight stay in a hospital or other inpatient facility.
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package Scheme Policy A combination of several different types of health insurance coverage.
[7]
participating provider Scheme Policy A participating provider is a provider who has a contract with the insurance scheme and who agrees to accept payment from that scheme as payment in full, except for any co-payments or deductibles which are due as part of the benefit plan.
[15]
patient Scheme Policy A person in contact with the health system seeking attention for a health condition.
[1]
patient-centered health care Scheme Policy Providing health care that is respectful of and responsive to individual patient preferences, needs and values and ensuring that patient values guide all clinical decisions. [2]
payer Scheme Policy An entity that assumes the risk of paying for medical treatments. This can be an uninsured patient, a self-insured employer, a health plan, or a HMO.
[7]
per-diem payments Scheme Policy For hospital stays, some insurance schemes provide for per-diem (“per-day”) payments of fixed amounts according to the particular category of the patient. Thus sicker patients (higher “acuity”) generally result in higher per-diem payments , and patients who require less nursing care and other services in lower payments.
[15]
performance Performance Management The extent to which the health system is meeting a set of key objectives.
[2]
performance measure Performance Management A quantitative measure of the quality of care provided by a health plan or provider that consumers, payers, regulators, and others can use to compare the plan or provider to other plans or providers.
[3]
personal health care expenditures National Policy Outlays for goods and services relating directly to patient care. The part of total national or state health expenditures spent on direct health care delivery, including hospital care, physician services, dental services, home health, nursing home care, and prescription drugs.
[7]
point-of-service (POS) plan Scheme Policy A plan that contains elements of both HMOs and PPOs. They resemble HMOs for in-network services in that they both require co-payments and a primary care physician. Services received outside of the network are usually reimbursed on a fee for service basis.
[5]
portability Scheme Policy The ability for an individual to transfer from one health insurer to another health insurer with regard to preexisting conditions or other risk factors. [9]
preadmission review Scheme Policy A review of an individual’s health care status or condition prior to an individual being admitted to a hospital or inpatient health care facility.
[9]
pre-authorization Scheme Policy A requirement that the physician obtains approval from the health plan prior to hospitalization or surgery or to prescribe a specific medication. Without this prior approval, the health plan may not provide coverage.
[10]
preexisting medical condition Scheme Policy A medical condition that is excluded from coverage by an insurance company because the condition was believed to exist prior to the individual obtaining a policy from the particular insurance company.
[8]Synonym: comorbid condition
preferred provider organization (PPO) Scheme Policy A network of health care providers with which a health insurer has negotiated contracts for its insured population to receive health services at discounted costs. Health care decisions generally remain with the patient as he or she selects providers and determines his or her own need for services. Patients have financial incentives to select providers within the preferred provider organization network.
[9]
premium Scheme Policy The amount paid to an insurance company or health plan in exchange for health insurance coverage, including paying for health-related services such as doctor visits, hospitalizations, and medications.
[10]Synonym: (health) insurance premium
prescription Performance Management A written authorization for a prescription medication given by a participating physician prescriber.
[7]Synonym: Rx
prevalence Performance Management The number of cases of disease, infected persons, or persons with some other attribute, present at a particular time and in relation to the size of the population from which drawn.
[7]Related term: incidence
prevalence rate Performance Management The proportion of persons in a population who have a particular disease or attribute at a specified point in time or over a specified period of time.
[7]
preventive care Scheme Policy An approach to health care which emphasizes preventive measures and health screenings such as routine physicals, well-baby care, immunizations, diagnostic lab and x-ray tests, pap smears, mammograms, and other early detection testing. The purpose of offering coverage for preventive care is to diagnose a problem early, when it is less costly to treat rather than late in the stage of a disease when it is much more expensive or too late to treat.
[9]
primary care Scheme Policy A basic level of health care provided by the physician from whom an individual has an ongoing relationship and who knows the patient’s medical history. Primary care services emphasize a patient’s general health needs, such as preventive services, treatment of minor illnesses and injuries, or identification of problems that require referral to specialists. [7]
primary care physician (PCP) Scheme Policy A physician who serves as a group member’s personal doctor and first contact in a managed care system.
[7]Synonym: primary care provider
primary health care (PHC) Scheme Policy General medical care that is provided directly to a patient without referral from another physician. It is focused on preventive care and the treatment of routine injuries and illnesses.
[3]
private expenditure on health National Policy The sum of outlays for health by private entities, such as commercial or mutual health insurance, nonprofit institutions serving households, resident corporations or quasi-corporations not controlled by government with a health services delivery or financing, and households.
[14]
proof of coverage Scheme Policy A document given to an insured that describes the benefits, limitations, and exclusions of coverage provided by an insurance company.
[9]Synonym: certificate of coverage, certificate of insurance
provider Scheme Policy A provider includes all caregivers and any others who have the right to claim payments under the insurance scheme. Most typically a provider is a professional person (physician, nurse, dentist, therapist) or a facility (hospital, clinic, home health agency) including suppliers of therapeutics (medications from a pharmacy, medical supplies from a store, orthopedic supplies, etc.
[15]Synonym: health care provider
provider agreement Scheme Policy Physician contract with a health insurance company, producing rules and billing regulations.
[7]
provider identifier Factory Computer numeric identifier given to a health care entity or provider for tracking and payment purposes.
[7]
provider manual Scheme Policy A document that contains information concerning a provider’s rights and responsibilities as part of a network.
[3]
provider profiling Scheme Policy The collection and analysis of information about the practice patterns of individual providers.
[3]
public health National Policy Activities that society undertakes to ensure the conditions in which people can be healthy. These include organized community efforts to prevent, identify, and counter threats to the health of the public. [5]

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qualifying conditions Scheme Policy Requirements for acceptance into an insurance plan; also describes the provisions that must be met before a benefit is payable.
[13]
quality assessment Performance Management Measurement of the quality of care.
[6]
quality assurance Scheme Policy Activities and programs intended to assure the quality of care in a defined medical setting.
[7]
quality assurance and quality improvement Performance Manaagement A systematic process to improve quality of health care by monitoring quality, finding out what is not working, and fixing the problems of health care delivery.
[6]
quality management Performance Management An organization-wide process of measuring and improving the quality of the health care provided by a health insurance payer.
[3]
quality of care Performance Management How well health services result in desired health outcomes.
[6]
quality of life Performance Management Quality of life is defined as an individual’s perceptions of their position in life in the context of the culture and value system where they live and in relation to their goals, expectations, standards, and concerns. It is a broad-ranging concept, incorporating in a complex way a person’s physical health, psychological state, level of independence, social relationships, personal beliefs, and relationship to salient features of the environment. [1]
quality-adjusted life year (QALY) Performance Management A measure of health improvement, measuring life expectancy adjusted for quality of life.
[5]Related to: disability-adjusted life years (DALYS)

R

 

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rate spread Scheme Policy The difference between the highest and lowest rates that a health plan charges to small groups.
[3]
rating Scheme Policy The process of calculating the appropriate premium to charge purchasers given the degree of risk represented by the individual or group, the expected costs to deliver medical services, and the expected marketability and competitiveness of the health insurance payer’s plan.
[3]Synonym: setting premiums
re-admission rate Performance Management Represents the rate at which patients return to the hospital within 30 days of discharge following an inpatient stay for a surgical procedure.
[17]
reconciliation Performance Management A method of applying premiums, dues, or bills to health insurance policies.
[7]
referral Scheme Policy A special kind of preapproval that health plan members must obtain from their primary care physician before seeing a specialist.
[10]
referral system Scheme Policy The process through which a primary care provider authorizes a patient to see a specialist to receive additional care.
[6]
reimbursement Scheme Policy The amount paid to providers for services they provide to patients.
[6]
reinsurance Scheme Policy The transfer of liability from the primary insurer, the company that issued the contract, to another insurer, the reinsurance company.
[13]
reinsurance policy Scheme Policy The amount charged by the reinsurer to accept an agreed amount of risk. [13]
resource allocation and planning (RAP) National Policy A way to allow market forces to work by fostering competitive negotiations between the purchasers of services (“payers”) and the providers of services (“providers”). Resource allocation and planning is characterized by a strong separation of duties, responsibilities, and accountabilities between “payer” and “provider” functions and responsibilities.
[2]
risk Scheme Policy The responsibility for profiting or losing money based on the cost of health care services provided. Traditionally, health insurance companies have carried the risk. Under capitation, health care providers bear risk.
[6]
risk adjustment Scheme Policy The statistical adjustment of outcomes measures to account for risk factors that are independent of the quality of care provided and beyond the control of the plan or provider, such as the patient’s gender and age, the seriousness of the patient’s condition, and any other illnesses the patient might have. Also known as case-mix adjustment.
[3]
risk factor Scheme Policy An attribute (for example, a lifestyle factor such as smoking or a personal characteristic such as age) or an exposure to an environmental factor associated with an increase in the probability that a specified health event (for example, onset of disease) will occur.
[13]
risk pooling Scheme Policy The practice of bringing several risks together for insurance purposes in order to balance the consequences of the realization of each individual risk.
[1]
risk rating Scheme Policy Technique for adjusting insurance premiums according to the relative risk insured.
[1]
risk segregation Scheme Policy Each individual faces his or her own risks without pooling. [13]
risk selection Scheme Policy The practice of singling out or disaggregating a particular risk from a pool of insured risks.
[1]
roster Scheme Policy A roster is a list of patients who are entrusted to a particular primary care physician (PCP). The roster contains the patients name, dob, sex, and possibly some other demographic information about that patient. A roster can be used to calculate capitation payments to a provider.
[15]Synonym: provider capitation list
roster cap Scheme Policy There is a maximum number of patients allowed on any one’s roster. This avoids the problem of having physicians sign up Insureds to their roster when they are unable to provide adequate services to the roster.
[15]

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safe health care Performance Management Avoiding injuries to patients from the care that is intended to help them.
[2]
schedule of benefits and exclusions Scheme Policy A health insurance listing of the benefits which are covered under the policy guidelines as well as services which are not provided under the policy.
[9]
scheme Scheme Policy See: health plan
secondary health care Scheme Policy Hospitals and outpatient specialist clinics to which people go after referral from primary health care services. These services are generally more specialized and further from where people live. They often include a greater range of diagnostic services such as X-ray and pathological laboratory services; they may also include specialized treatment such as surgery, radiotherapy, and certain drug therapies not normally available in primary care. The principal difference between primary and secondary services is in the range and specialization of the staff available.
[1]
service Scheme Policy Medical care and items, such as medical diagnosis and treatment; drugs and biologicals; supplies, appliances, and equipment; medical social services; and use of hospital, rural primary care hospital, or skilled-nursing facilities.
[7]
service-level agreement Factory The agreements that are fundamental to both providers and payers. They define the terms of engagement and rules that govern the relationship. [2]
sickness fund National Policy A third-party payer in a social health insurance system covering the community as a whole or sections of the population. Sickness funds are usually quasi-public bodies. Synonyms are “sick funds” and “health insurance funds.”
[2]
social insurance Scheme Policy Compulsory plan under which participants are entitled to certain benefits as a matter of right. The plan is administered by a state or federal government agency aimed at providing a minimum standard of living for lower and middle wage groups. Social Security, unemployment compensation, etc., are social insurance programs.
[7]
specialist Scheme Policy Any health professional who has specific training and certification in a particular area of medical care.
[7]
standard benefit package Scheme Policy A defined set of benefits provided to all people covered under a health plan.
[6]
standard of care Scheme Policy A clinical protocol that is agreed upon by the involved professional community.
[7]
subsidy Scheme Policy A payment made by the government with the object of reducing the market price of a particular product or of maintaining the income of the producer.
[1]
survey Performance Management Systematic collection of information from a defined population, usually by means of interviews or questionnaires administered to a sample of units in the population. [7]

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target population Scheme Policy Cohort based on age, gender, clinical focus, and target geographic areas.
[7]Synonym: target group
tertiary health care Scheme Policy Specialized care that offers a service to those referred from secondary care for diagnosis or treatment and which is not available in primary or secondary care. This kind of care is generally only available at national or international referral centres. Tertiary care has become a common feature in certain specialties for rare conditions, or where the diagnostic or treatment facilities are scarce or require scarce combinations of resources, or which remain essentially the subject of research. These facilities are commonly found in medical schools and teaching hospitals.
[1]
third party administrator (TPA) Scheme Policy An organization that processes health plan claims but does not carry any insurance risk.
[6]
third-party payer Scheme Policy An organization other than the patient or health care provider involved in the financing of personal health services.
[6]
timeliness Performance Management Reducing waits and sometimes harmful delays for both those who receive and those who give care. [2]
total expenditure on health National Policy Funds mobilised by the system. Sum of general government and private expenditure on health
[14]
transaction costs Scheme Policy The costs additional to the price of a good or service, arising, for example, from search costs, travel costs, marketing and distribution, or transfer of ownership costs.
[13]
treatment Scheme Policy Patient care intended to correct or relieve the underlying problem and its symptoms.
[7]

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uncompensated care National Policy Health care provided to people who cannot pay for it and who are not covered by any insurance. This includes both charity care which is not billed and the cost of services that were billed but never paid.
[6]
under-5 mortality rate Performance Management The mortality rate of children between birth and five years.
[14]
underinsured Scheme Policy People who have some type of health insurance but not enough insurance to cover their the cost of necessary health care. This includes people who have very high deductibles or insurance policies that have specific exclusions for costly services.
[6]
underwriter Scheme Policy The company that assumes responsibility for the risk, issues insurance policies, and receives premiums. [8]
underwriting Scheme Policy The act of reviewing and evaluating prospective insured persons for risk assessment and appropriate premium.
[9]
underwriting impairments Scheme Policy Factors that tend to increase an individual’s risk above that which is normal for his or her age.
[3]
uninsured Scheme Policy People who do not have any health insurance of any type.
[6]
unique identifier (UID) Factory With reference to a given set of objects, a unique identifier (UID) is any identifier which is guaranteed to be unique among all identifiers used for those objects and for a specific purpose. There are three main types of unique identifiers: serial numbers, random numbers, and names or codes allocated by choice which are forced to be unique by keeping a central registry.
[4]
universal coverage National Policy (1) to ensure that health-financing systems include a method for prepayment of financial
contributions for health care, with a view to sharing risk among the population and avoiding
catastrophic health-care expenditure and impoverishment of individuals as a result of seeking
care;
(2) to ensure adequate and equitable distribution of good-quality health care infrastructures
and human resources for health so that the insurees will receive equitable and good-quality
health services according to the benefits package;
(3) to ensure that external funds for specific health programmes or activities are managed and organized in a way that contributes to the development of sustainable financing mechanisms for the health system as a whole;
(4) to plan the transition to universal coverage of their citizens so as to contribute to meeting
the needs of the population for health care and improving its quality, to reducing poverty, to
attaining internationally agreed development goals, including those contained in the United
Nations Millennium Declaration, and to achieving health for all;
(5) to recognize that, when managing the transition to universal coverage, each option will
need to be developed within the particular macroeconomic, sociocultural and political context of each country;
(6) to take advantage, where appropriate, of opportunities that exist for collaboration between
public and private providers and health-financing organizations, under strong overall
government stewardship;
(7) to share experiences on different methods of health financing, including the development
of social health-insurance schemes, and private, public, and mixed schemes, with particular
reference to the institutional mechanisms that are established to address the principal functions of the health-financing system.
[20]Synonym: universal health coverage
upcoding Performance Management A coding inconsistency that involves using a code for a procedure or diagnosis that is more complex than the actual procedure or diagnosis and that results in higher reimbursement to the provider.
[3]
urgent care Scheme Policy Health care provided in situations of medical duress that have not reached the level of emergency. Claim costs for urgent care services are typically much less than for services delivered in emergency rooms.
[9]Synonym: immediate care
user fees Scheme Policy Charges payable by users, usually at the point of service.
[13]
utilization Performance Management How many times people use particular health care services during particular periods of time.
[6]
utilization guidelines Scheme Policy A utilization review resource that indicates accepted approaches to care for common, uncomplicated health care services.
[3]
utilization review Performance Management An evaluation of the medical necessity, appropriateness, and cost-effectiveness of healthcare services and treatment plans for a given patient. [3]

Synonym: utilization management

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voluntary care Scheme Policy Care, usually by a family member. The market price is zero, but there is an opportunity cost in terms of the alternative ways in which the carer could have utilized the time. A value would have to be imputed, perhaps based on the salary of a paid caregiver.
[5]

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waiting period S Policy A period of time when the health plan does not cover a person for a particular health problem.
[9]
willingness to pay Scheme Policy How much a person or group is prepared to pay for particular goods or services.
[1]
withhold Scheme Policy A percentage of providers’ fees that managed care companies hold back from providers which is only given to them if the amount of care they provide (or that the entire plan provides) is under a budgeted amount for each quarter or the whole year.
[6]

X

 

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Y

 

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Z

 

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yearly maximum payments Scheme Policy The maximum amount which an insurance scheme must pay for an insured during any one year period. [15]

Sources

The definitions have been adapted from the following sources:
1 WHO, Health promotion glossary, 1998
Roberts, J.L., A Glossary of Technical Terms on the Economics and Finance of Health Services, WHO, 1998
2 Streveler, D.J. & Sherlock, S.M., Health Management Information Systems for Resource Allocation and Purchasing in Developing Countries, HNP Discussion Paper, September 2004
3 BlueCross BlueShield Association, http://www.bcbs.com/coverage/glossary/. Accessed April 12, 2011
4 Wikipedia, http://www.wikipedia.org. Accessed June 24, 2011
5 National Information Center on Health Services Research and Health Care Technology, http://www.nlm.nih.gov/nichsr/edu/healthecon/glossary.html. Accessed April 15, 2011
6 PBS, http://www.pbs.org/healthcarecrisis/glossary.htm
7 Marcinko, D.E., Dictionary of Health Insurance and Managed Care, 2006
8 Health insurance glossary, http://www.healthinsurance.org/glossary/. Accessed April 12, 2011
9 Glossary of health insurance terms, http://www.medplanaccess.com/glossary.htm. Accessed April 12, 2011
10 About.com, http://healthinsurance.about.com/. Accessed April 12, 2011
11 http://web.worldbank.org. Accessed May 20, 2011
12 WHO Expert Committee on Drug Dependence. Sixteenth Report. (Technical Report Series. No. 407) 1969
13 Dror, M.D. & Preker, A.S., Social Reinsurance. A New Approach to Sustainable Community Health Financing. World Bank / ILO, 2002
14 Course materials of e-learning course Basics of Health Economics by World Bank Institute
15 Streveler, D.J., Health insurance information systems glossary v2b
16 http://www.treatment-now.com/definitions. Accessed June 24, 2011
17 http://health.usnews.com. Accessed June 24, 2011
18 http://www.if4it.com. Accessed June 24, 2011
19 Caroll, P., Actuarial Management of Health Funds in Australia. The Institute of Actuaries in Australia, 2007
20 Resolution WHA58.33. Sustainable health financing, universal coverage and social health insurance. In: 58th World Health Assembly, World Health Organization, 2005 (http://apps.who.int/gb/ebwha/pdf_files/WHA58/WHA58_33-en.pdf, accessed 29 June 2011).