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Cafeteria Plan - Preparations under which employees may choose their own benefit structure. Sometimes these are unreliable benefit plans or add-ons provided through the same insurer or 3rd party administrator, other times this refers to the contribution of different plans or HMOs provided by dissimilar managed care or insurance companies.

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Calendar Year - A 12 month period of time start from January 1 and ending on December 31.

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Capital Costs - Capital costs generally involve equipment and physical plant costs, not consumable supplies. Included in these costs can be interest, leases, rentals, taxes and insurance on substantial assets like plant and equipment. Capital costs are usually reimbursed to cost based services through submission of these costs on annual cost information to the CMS intermediaries.

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Capital Expenditure Review - The review of planned capital expenditures of hospitals or providers to determine the need for, and correctness of, the proposed expenditures. The review is usually done by a chosen regulatory agency and has a sanction attached that prevents or discourages not needed expenditures. Often this is connected to CMS or Medicare and the willingness of the federal government to supply allowances for capital costs.

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Capital Cost Report - Related to the above review but normally produced retrospectively rather than prospectively.

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Capitation - Specified amount paid occasionally to health provider for a group of specified health services, regardless of quantity rendered. Amounts are resolute by assessing a payment "per covered life" or per member. The method of payment in which the contributor is paid a fixed amount for each person served no matter what the real number or nature of services delivered. The cost of providing an individual with an exact set of services over a set period of time, usually a month or a year.

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Carrier - An insurer; a sponsor of risk that finances health care. Also refers to any organization, which underwrites or administers life, health or further insurance programs. When an employer has a self-insured plan, the carrier may not serve as carrier in this case, but may provide only as third party administrator.

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Carve-in - A common term that refers to any of a continuum of joint efforts between clinicians and service providers also used specially to refer to health care delivery and financing arrangements in which all enclosed benefits are administered and funded by an incorporated system.

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Case Management - Method planned to accommodate the specific health services needed by an individual through a synchronized effort to achieve the desired health outcome in a cost effective manner. The monitoring and organization of treatment rendered to patients with specific diagnosis or requiring high-cost or wide services. Physician case managers coordinate designated mechanism of health care, such as appropriate referral to consultants, specialists, hospitals, ancillary provider and services.

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Case Manager - A nurse, doctor, or social employee who works with patients, providers and insurers to coordinate all services deemed necessary to offer the patient with a arrangement of medically necessary and appropriate health care.

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Case Mix - The mix of patients treated within a fastidious institutional setting, such as the hospital. Patient classification systems like DRGs can be used to calculate hospital case mix. Measurement dazzling servicing needs uses of hospital capabilities, and the common rate of hospital admissions. The types of inpatients a hospital or place acute facility treats. Case mix is generally recognized by estimating the relative frequency of various types of patients seen by the provider in question through a given time period and may be considered by factors such as diagnosis, severity of illness, utilization of services, and provider characteristics.

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Case-Mix Index (CMI) - The standard DRG weight for all cases paid under PPS. The CMI is an estimation of the relative costliness of the patients treated in each hospital or group of hospitals. Measure of the relative costliness of treating in an inpatient location. An index of 1.05 means that the facility's patients are 5 % extra costly than average.

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Case Rate - Flat fee paid for a client's treatment based on their analysis and/or presenting problem. For this fee the provider covers all of the services the clients require for a specific period of time it is also bundled rate or Flat Fee-Per-Case. In this representation, the provider is accepting some significant risk, but does have considerable flexibility in how it meets the client's requirements. Keys to achievement in this mode: (1) properly pricing case rate, if provider has managed over it, and (2) securing a large volume of qualified clients.

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Case Severity - A measure of strength or gravity of a given condition or diagnosis for a patient. May have express correlation with the amount of service provided and the connected costs or payments allowed.

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Catastrophic Case - Any medical condition for which the entire cost of treatment exceeds levels expected by the health plan.

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Catastrophic Health Insurance - Policy that provides to secure primarily against the higher costs of treating severe or lengthy illnesses or disabilities. Normally these are "add on" benefits that start coverage once the primary insurance policy reaches its maximum.

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Categorically Needy - Medicaid eligibility based on defined indicators of financial require by families with children and pregnant women, and to persons who are aged, blind, or disabled. Persons not falling into these categories cannot be eligible, no matter how low their income. The Medicaid act defines over 50 distinct population groups as potentially eligible, including those for which exposure is mandatory in all states and those that may be covered at a state's option.

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Catastrophic Health Insurance - Health insurance which provides security against the high cost of treating severe or lengthy illnesses or disability. Normally such policies cover all, or a particular percentage of, medical expenses above an amount that is the responsibility of another insurance policy up to a most limit of liability.

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Centers for Medicare and Medicaid Services (CMS) - The Centers for Medicare & Medicaid Services (CMS) is a Federal organization within the U.S. Department of Health and Human Services. A program for which CMS is dependable includes Medicare, Medicaid, State Children's Health Insurance Program (SCHIP), HIPAA and CLIA. Previously was HCFA. Centers for Medicare & Medicaid Services has historically maintained the UB-92 institutional EMC format specifications, the professional EMC NSF specifications, and specifications for a variety of certifications and authorizations used by the Medicare and Medicaid program.

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Certificate - The certificate which has been issued to you and which summarize the terms, conditions and limitations of your health care coverage.

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Certificate Booklet - The plan agreement. A printed description of the benefits and coverage provisions intended to explain the contractual arrangement between the carrier and the insured group or individual. May also be referred to as a policy booklet.

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Certificate of Authority (COA) - Issued by state governments, it gives a health protection organization or insurance company its license to operate within the state.

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Certificate of Coverage (COC) - Outlines the conditions of coverage and benefits available in a carrier's health plan.

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Certificate of Need (CON) - In some states, a state agency must assess and approve certain proposed capital expenditures, changes in health services provided, and purchase of expensive medical equipment. Before the request goes to the state, a local review panel must evaluate the proposal and make a recommendation. CON is planned to control expansion of facilities and services by preventing excessive or duplicative development of facilities and services. Many states contain sunsetted or eliminated their CON processes and requirements.

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Certified Health Plan - A managed health care plan, specialized by the Health Services Commission and the Office of the Insurance Commissioner to provide coverage for the Uniform Benefits Package to state people. Regulations vary by state as some states require only HMOs to certify but not PPOs, IPAs or MSOs. Increasingly these regs are becoming more reliable state by state.

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Chain of Trust Agreement - Referred to in HIPAA rules, this is a agreement needed to extend the responsibility to protect health care data transversely a series of sub-contractual relationships.

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CHAMPUS - The Uniformed Services for the Civilian Health and Medical Program.

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Change of Status Form - The form obtainable from your employer that you must complete if you wish to add or delete dependents or alter the information contained on your Enrollment Form.

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Charges - These are the available prices of services provided by a facility. CMS requires hospitals to relate the same schedule of charges to all patients, regardless of the expected sources or amount of payment. Argument exists today because of the often wide disparity between published prices and contract prices. The majority of payers, together with Medicare and Medicaid, are becoming managed by health plans that negotiate rates lower than published prices. Often these negotiated rates average 40% to 60% of the published rates and may be all-inclusive bundle rates.

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Chronic Care - Long term care of individuals with long position, persistent disease or conditions. It include care specific to the problem as well as other measures to encourage self-care, to promote health, and to avoid loss of function.

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Claim - A demand by an individual to that individual's insurance company to reimburse for services obtained from a health care professional.

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Claim Determination Period - It is a calendar year from January 1 to December 31. However, it does not include any element of a year during which a person has no coverage under the policy.

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Claims Review - The technique by which an enrollee's health care service claims are reviewed prior to reimbursement. The reason is to validate the medical necessity of the provided services and to be sure the cost of the service is not extreme.

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Claim Status Codes - A national managerial code set that identifies the status of health care claims. This code set is used in the X12N 277 Claim Status Inquiry and Response transaction, and is maintained by means of the Health Care Code Maintenance Committee.

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Clinical Data Repository - That component of a computer-based patient documenter which accepts, files, and stores clinical data more time from a variety of supplemental treatment and interference systems for such purposes as practice guidelines, outcomes management, and clinical research.

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Clinical Decision Support - The ability of a data system to provide key data to physicians and other clinicians in response to flags or triggers which are functions of embedded, provider-created rules. A system that would prepared case managers that a client's eligibility for a certain service is about to be exhausted would be one example of this type of capacity. Also a key useful requirement to support clinical or critical pathways.

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Clinical Laboratory Improvement Amendments (CLIA) - CMS regulates all laboratories testing performed on human in the U.S. through the Clinical Laboratory Improvement Amendments. In total CLIA covers around 175,000 laboratory entities. The Division of Laboratory Services, contained by the Survey and Certification Group, under the Center for Medicaid and State Operations has the responsibility for implementing the CLIA Program. The purpose of the CLIA program is to ensure quality laboratory testing. Although all clinical laboratories must be correctly certified to receive Medicare or Medicaid payments, CLIA has no straight Medicare or Medicaid program responsibilities.

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Clinical Record - The section of the medical record that relates to the evaluation, diagnosis, treatment and diagnosis of the patient.

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Clinical or Critical Pathways - A map of favored treatment/intervention activities. Outlines the types of information required to make decisions, the timelines for applying that information, and what action needs to be taken by whom. Provides a way to check care in real time. These pathways are developed by clinicians for definite diseases or events.

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Clinic Without Walls (CWW) - Related to an independent practice association and identical to a practice without walls. Practitioners form CWWs and PWWs when they want the economy of scale and bargaining power accessible by centralizing some administrative functions, but still choosing to practice separately. Many of these were fashioned to allow practitioners the capacity to effectively contract with managed care.

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Clinician - A physician supporter, clinical nurse practitioner, nurse midwife, medical technician, physical therapist, and other similar health care providers that give services under the supervision of a participating provider.

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Closed Access - Gatekeeper model health plan that requires enclosed persons to receive care from providers within the plan's coverage. Except for emergencies, the patient might only be referred to and treated by providers within the plan. A managed health care agreement in which covered persons are required to select providers only from the plan's participating providers.

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Closed Panel - Medical services are delivered in the HMO-owned health center or satellite clinic by physicians who belong to a specially shaped, but legally separate, medical group that only serves the HMO. This expression usually refers to a group or staff HMO models.

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Coded Data - Data are divided from personal identifiers through use of a code. As long as a link exists, data are considered not directly identifiable and not anonymous or anonymized. Coded data are not enclosed by the HIPAA Privacy Rule, but are protected under the Common Rule.

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Code Set - Under HIPAA, this is any set of code used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes. This includes together with codes and their descriptions.

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Coding - A method for identifying and defining physician's and hospital's services. Coding provides universal description and recognition of diagnoses, procedures and level of care. Medicare fraud investigators look intimately at the medical record documentation, which supports codes and looks for consistency. National certifications exist for coding professionals and many compliance programs are raising standards of quality for their coding procedures.

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Co-Insurance (coinsurance) - A cost-sharing condition under a health insurance policy that provides that the insured will believe a portion or percentage of the costs of covered services. A policy provision regularly found in major medical insurance policies under which the insured individual and the insurer split hospital and medical expenses according to a specified ratio. A type of cost sharing where the insured party and insurer share expense of the approved charge for covered services in a specific ratio after payment of the deductible.

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Commercial Plan - Health insurance policies accessible to employers and individual purchasers.

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Community Care Network (CCN) - This vehicle provides synchronized, organized, and comprehensive care to a community's population. Hospitals, primary care physicians, and specialists link defensive and treatment services through contractual and financial arrangements, producing a network that provides coordinated care with constant monitoring of quality and accountability to the public.

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Community Health Center (CHC) - An ambulatory health care program usually helping a catchment area which has scarce or nonexistent health services or a population with special health needs. It is sometimes known as the neighborhood health center. Community Health Centers attempt to coordinate federal, state and local assets into a single organization capable of delivering both health and related social services to a defined population. While such a center may not indirectly provide all types of health care, it usually takes responsibility to arrange all medical services needed by its patient populace.

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Community Health Information Network (CHIN) - An incorporated collection of computer and telecommunication capabilities that allow multiple providers, payers, employers, and related healthcare entities within a geographic area to split and communicate client, clinical, and payment information.

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Comorbid Condition - A medical state that, along with the principal diagnosis, exists at admission and is estimated to increase hospital length of stay by at least one day for most patients.

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Competitive Bidding - This can be viewed by some as a pricing method that elicits information on costs through a request process to establish payment rates that reflect the costs of a proficient health plan or health care provider. Competitive request is also the procedure of offering reduced rates to health plans to get exclusive contracts from payers.

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Competitive Medical Plan (CMP) - The category of MCO created by the 1982 Tax Equity and Fiscal Responsibility Act to assist the enrollment of Medicare beneficiary into managed care plans. Competitive medical plans are prepared and financed much like HMOs but are not bound by all the regulatory requirements facing HMOs. A health plan can be entitled for a Medicare risk contract if it meets specified necessities for service provision, capital, risk protection, and financial solvency.

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Compliance - Exactly following the government's rules on Medicare billing system necessities and other federal or state regulations. A compliance program is a self-monitoring system of checks and balances to guarantee that an organization consistently complies with applicable laws relating to its business activities.

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Complaint - A verbal expression of any disappointment with our administration, claims practices, or provision of services, expressed by you or an authorized representative.

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Complication - A medical condition that arises throughout a course of treatment and is expected to increase the length of stay by at least one day for most patients.

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Composite Rate - Group rate allocated to all subscribers of a given group.

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Comprehensive Major Medical Insurance - A policy intended to provide the protection offered by both a basic and major medical health insurance policy. It is generally characterized by a small deductible, a co-insurance feature, and high maximum benefits.

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Computer-Based Patient Record (CPR) - A term for the process of replace the traditional paper-based chart through automated electronic means generally includes the set of patient-specific information from various supplemental treatment systems.

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Concurrent Review - Review of a procedure or hospital admission done by a health care professional other than the one given that the care, during the same time frame that the care is provided.

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Confidentiality - The security of individually identifiable information as required by state or federal law or by policy of the healthcare provider.

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Consolidated Omnibus Budget Reconciliation Act (COBRA) - Federal law that continues health care benefits for employees whose employment has been ended. Employers are essential to notify employees of these benefit continuation options, and crash to do so can result in penalties and fines for the employer. An act that allows workers and their families to maintain their employer sponsored health insurance for a certain amount of time after terminating employment. COBRA imposes different limits on individuals who leave their jobs voluntarily versus involuntarily.

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Consumer Health Alliance - Regional cooperatives between government and the public that will supervise the new payment system. Once all health insurance purchasing cooperatives the alliance would make sure health plans within an area conformed to federal coverage and quality standards, and oversee costs within any mandate budget.

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Continued Stay Review - A review conducted by an internal or external auditor to decide if the current place of service is still the most suitable to provide the level of care required by the client.

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Continuous Quality Improvement (CQI) - An approach to health care eminence management borrowed from the manufacturing sector. It builds on traditional quality declaration methods by putting in place a management structure that continuously gathers and assesses data that are then used to develop performance and design more efficient systems of care.

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Continuity of Care - The quantity to which the care of a patient over time is provided and/or managed by the same provider.

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Contract - A legal conformity between a payer and a subscribing group or individual which specifies rates, performance covenants, the relationship among the parties, program of benefits and other pertinent conditions. Contracts are not necessary by statute or regulation, and less formal agreements may be made.

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Contract Year - A period of twelve consecutive months, beginning with each Anniversary Date.

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Contract Provider - Any hospital, physician, skilled nursing facility, extended care facility, individual, organization, or agency approved that has a contractual arrangement with an insurer for the condition of services under an insurance contract.

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Contributory Program - Program where the employee and the employer or the union share the cost of group coverage.

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Conversion Factor - The dollar amount used to increase the Relative Value Schedule of a procedure to arrive at the maximum allowable for that procedure.

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Conversion Privilege - The right of an individual insured under a group policy to convinced kinds of individual coverage, without a medical examination, upon extinction of his association with the group.

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Coordination of Benefits (COB) - Provision regulating expenditure to eliminate duplicate coverage when a claimant is covered by multiple group plans. The procedures set onward in a Subscription Agreement to determine which coverage is primary for payment of benefits to Members with duplicate coverage. A coordination of remuneration or nonduplication clause in either policy prevents double payment by creation of one insurer the primary payer, and assuring that not more than 100 percent of the cost is covered.

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Co-Payment, Copayment, Copay - A cost-sharing agreement in which the HMO enrollee pays a particular flat amount for a specific service the amount paid must be insignificant to avoid becoming an obstacle to care. It does not vary with the cost of the service and is typically a flat sum amount such as $10 for each prescription or doctor visit, unlike co-insurance that is based on a percentage of the cost.

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Cost-benefit analysis - An analytic method, in which a program's cost is compared to the program's reimbursement for a period of time, expressed in dollars, as an aid in influential the best investment of resources. For instance, the cost of establishing an immunization service might be compared with the entire cost of medical care and lost productivity that will be eliminated as a result of more persons being immunized. Cost-benefit analysis can also be applied to specific medicinal tests and treatments.

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Cost Consequence Analysis (CCA) - A form of analysis that compares other interventions or programs in which the components of incremental costs and consequences are planned without aggregation.

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Cost Effectiveness - The efficiency of a program in achieving given intervention outcomes in relation to the program costs. Follow-up studies, outcome studies and TQM programs effort to assess treatment efficacy, while cost effectiveness would provide a ratio of this dimension with costs. This analysis may decide the costs and effectiveness of certain interventions compared to similar alternative interventions, determining the comparative costs and degree to which they will obtain preferred health outcomes.

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Cost Minimization Analysis (CMA) - An estimation of the least costly interventions among available alternatives that produce corresponding outcomes.

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Cost of Illness Analysis (COI) - An assessment of the economic contact of an illness or condition, including treatment costs.

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Cost Sharing - Payment technique where a person is required to pay some health costs in order to receive medical care. The general set of financing arrangements whereby the customer must pay out-of-pocket to receive care, either at the time of initiating care, or during the provision of health care services, or both.

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Cost Shifting - Charging one set of patients more in order to make up for underpayment by others. Most frequently, charging some privately insured patients more in order to make up for underpayment by Medicaid or Medicare.

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Cost Utility Analysis - A form of efficiency analysis where outcomes are rated in terms of utility, or quality of life.

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Coverage - The guarantee against specific losses provided under the conditions of an insurance policy.

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Covered Services - Services provided within a specified health care plan. Health care services provided or certified by the payer's Medical Staff or payment for health care services.

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Covered Benefit - A medically necessary service that is specially provided for under the provisions of an Evidence of Coverage. A covered benefit must always be medically essential, but not every medically necessary service is an enclosed benefit. For example, some essentials of custodial or maintenance care, which are excluded from coverage, may be medically necessary, but are not enclosed.

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Covered Entity - Under HIPAA, this is a health plan, a health care clearinghouse, or a health care supplier who transmits any health information in electronic form in association with a HIPAA transaction. For purpose of the HIPAA Privacy Rule, health care providers include hospitals, physicians, and other caregivers, as well as researchers who provide health care and receive access or produce individually identifiable health care information.

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Credit for prior coverage - Any pre-existing condition waiting period met under an employer's prior (qualifying) coverage will be credited to the current plan, if any interruption of coverage between the new and prior plans meets state guidelines.

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Current Dental Terminology (CDT) - A medical code set of dental procedures, maintained and copyrighted by the American Dental Association, and adopt by the Secretary of HHS as the normal for reporting dental services on standard transactions.

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Current Procedural Terminology (CPT) - A regular mechanism of reporting services using numeric codes as recognized and updated annually by the AMA. The coding system for physician's services residential by the CPT Editorial Panel of the American Medical Association, basis of the Medicare coding system for physician's services.

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Customary, prevailing, and reasonable (CPR) - Present method of paying physicians under Medicare. Payment for a service is partial to the lowest for the physician's billed charge for the service and physician's customary charge for the service. The prevailing accuse for that service in the community.

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