Ancillary

Products and services outside of MD, DO, and Hospital providers, received during the course of care. This excludes room, board, medical, and nursing services. Examples of ancillary care would be home health care needs (equipment, supplies, etc.), free standing laboratories, radiology, pharmacy, physical therapy, etc.

Appeal

A review carried out by a physician after services have been denied. The physician reviewing the appeal is a different physician than the initial reviewer.

Browser

The program with which you view Web pages, on the Internet. The most common browsers are Microsoft’s Internet Explorer and Netscape’s Navigator (or Communicator).

Cache

Temporary files stored on your computer’s hard drive. Your cache holds all the components of the Web pages you’ve visited. The computer will refer to these files to bring up the Web page faster at a later date, sometimes instead of loading a more current version of the page (depending on your computer settings).

Case Management

A process where a nurse assesses, plans, implements, coordinates, monitors, and evaluates services to meet a patient’s health needs. Communication with the patient and physician helps the case manager access resources to assist the patient and promote quality, cost effective care.

Concurrent Review

Utilization management carried out during a patient’s hospital admission or course of treatment.

Continued Stay Review

Utilization management carried out during a patient’s hospital admission or course of treatment.

Cookies

On a Web site, information saved on a visitor’s hard drive to help keep track of where they’ve been on the site and how they’ve used the pages.

Co-payment

That portion of a health expense for which a patient is responsible for paying.

CPT

See “current procedural terminology”.

Credentialing

The process of reviewing a provider’s history, including licensing, certifications, evidence of malpractice insurance, malpractice history, etc.

Current Procedural Terminology

5-digit codes that represent medical services and procedures rendered by physicians and other providers. Used on health claims.

Date(s) of Service

Date(s) on which medical service was actually rendered.

DAW

See “dispense as written”.

Deductible

A portion of the patient’s health care expenses that must be paid by the patient, before full insurance benefits apply.

Disease Management

Programs to manage chronic illnesses such as diabetes, asthma, and congestive heart failure. These programs utilize nurses to assess, educate, and counsel patients related to their disease process and quality of life while making the best use of medical resources.

Disenrollment

Termination of coverage. Voluntary termination occurs when members quit the plan of their own volition. Involuntary termination occurs when members leave the plan due to a change in employment (from one company to another).

Dispense As Written

Instructions given to a pharmacist from a physician, to fill the prescription exactly as described – without generic substitution.

DME

See “durable medical equipment”.

DOS

See “date(s) of service”.

Durable Medical Equipment

Non-disposable medical equipment (like wheelchairs, walkers, etc.) directly related to care for a certain medical condition.

EOB

See “explanation of benefits”.

Explanation Of Benefits

A document that explains to the member what was paid on a particular claim or why a claim was not paid.

External Review

Utilization management carried out by a physician who is independent of the patient, insurance company, utilization management vendor, and attending physician. Usually this service is provided when all appeal options have expired.

Formulary

A list of drugs covered by a health plan. Physicians must adhere to this list, unless a medical reason can be found for using a non- formulary drug.

Health Maintenance Organization

An organization that manages a system for delivering health care in a given area, a predetermined set of treatment services, and enrolled groups of patients. Some HMOs use primary care physicians as “gatekeepers” for determining necessary services for a patient.

HMO

See “health maintenance organization”.

Independent Review

Utilization management carried out by a physician who is independent of the patient, insurance company, utilization management vendor, and attending physician. Usually this service is provided when all appeal options have expired.

In-network

A provider who is actively participating in a designated provider network.

ISP

See “internet service provider”.

Internet Service Provider

A company that provides access to the Internet and Internet-related services.

MAC

The maximum, although not the minimum, that a vendor may charge for something.

Managed Care Organization

A generic term applied to a managed care plan. Some people prefer it to the term HMO. May also apply to a PPO, EPO, or OWA.

Managed Health Care

A system of health care delivery that tries to manage the cost of health care, the quality of that health care, and access to that care.

Maximum Allowable Charge (or cost)

The maximum, although not the minimum, that a vendor may charge for something. This term is often used in pharmacy contracting; a related term, used in conjunction with professional fees, is fee maximum.

MCE

See “medical care evaluation”.

MCO

A generic term applied to a managed care plan. Some people prefer it to the term HMO. May also apply to a PPO, EPO, or OWA.

Medical Care Evaluation

A component of a quality assurance program that looks at the process of medical care.

Non-par

Providers that are not participating in a designated network.

Open Enrollment Period

The period when an employee may change or join a health plan.

Out-of-network

A provider who is not participating in a designated network.

Payor (or Payer)

(also called carrier) An organization that provides, pays for, or reimburses all or some of the cost of health care services to groups covered by their health insurance plan(s).

PCP

See “primary care physician (or provider)”

PPO

A Preferred Provider Organization (PPO) contracts with independent providers for discounted services. Providers join the network and agree to the discounted rates, while payors (like insurance companies) join the PPO to utilize this network of services.

Preadmission certification

Utilization management carried out before a patient’s hospital admission or treatment.

Preadmission review

Utilization management carried out before a patient’s hospital admission or treatment.

Preauthorization

Utilization management carried out before a patient’s hospital admission or treatment.

Precert

Utilization management carried out before a patient’s hospital admission or treatment.

Precertification

Utilization management carried out before a patient’s hospital admission or treatment.

Primary Care Physician (or Provider)

Generally applies to internists, pediatricians, family physicians, and general practitioners and occasionally to obstetrician/gynecologists.

CareVu considers a Primary Care Physician to be a physician with any of the following 5 specialties: (1) General Practice; (2) Family Practice; (3) Internal Medicine; (4) Obstetrics/Gynecology; and (5) Pediatrics.

Prior Authorization

Utilization management carried out before a patient’s hospital admission or treatment.

Prospective Review

Utilization management carried out before a patient’s hospital admission or treatment.

Provider

Any physician, specialist, hospital, or ancillary facility, which provides health equipment, products, or services.

Reduction of Benefits

Refers to a reduction in the amount of health costs covered by a health plan, should a patient choose an out-of-network provider or fail to properly precertify certain procedures or in-patient care.

Referral

A request for additional care, made by the Primary Care Physician (PCP), to be provided by another specialist.

Refresh

A button found on your Web browser that forces the browser to reload the current page and retrieve a more current version of the page. May also be a “Reload” button.

Reload

A button found on your Web browser that forces the browser to reload the current page and retrieve a more current version of the page. May also be a “Refresh” button.

Reprice

The process through which a PPO applies discounts to provider charges, before forwarding the claims to insurance companies to be paid.

Retrospective Review

Utilization management carried out after medical services or treatment have been provided to the patient.

Tax I.D. Number

The number assigned to the provider for tax purposes. It is also often used as an I.D. # for the provider.

Third-Party Administrator

A firm that performs administrative functions (eg, claims processing, membership, and the like) for a self-funded plan or start-up managed care plan (also see ASO).

TPA

See “third-party administrator”

UM

See “utilization management”

UR

Utilization Review (See “utilization management”)

URAC

See “utilization review accreditation commission”

Utilization Management

Term used to describe the medical review of health care services for medical necessity, appropriate level of care (e.g., hospital admission, home health), and proper use of health care services.

Utilization Review

See “utilization management”

Utilization Review Accreditation Commission

A not-for-profit organization that performs reviews on external utilization review agencies. Its sole focus is managed indemnity and PPOs, not HMOs or similar types of plans. States often require certification by URAC for a utilization management organization to operate.