Home Page |  About Us  |  FAQ's  |  Providers  | Applications  | California Birth Profiles  Contact Us 

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

Data Aggregation - To combine the sets of protected health information by a business associate to permit data analysis.

Back to top

Database Management System (DBMS) - The separation of data from the computer application which allows entry or editing of data.

Back to top

Data Condition - An explanation of the circumstances in which certain data is required.

Back to top

Data Content - Under HIPAA, this is all the data essentials and code sets intrinsic to a transaction, and not related to the format of the transaction.

Back to top

Data Mapping - The process of matching one set of data elements or individual code principles to their closest equivalent in another set of them. This is sometimes also called as cross-walk.

Back to top

Data Use Agreement (DUA) - HIPAA Regulation states that a health care unit may use or disclose a limited data set. If that entity obtains a data use concurrence from the potential recipient and can only be used for research, public health or healthcare operations. An acceptable assurance between the covered entity and a researcher using a restricted data set that the data will only be used for specific uses and disclosures. The data use agreement is necessary to include the following information such as to establish that the data will be used for research.

Back to top

Data Warehouse - A specific database containing data from many sources that are associated by a common subject.

Back to top

Days Per Thousand - A regular unit of measurement of utilization. It is the number of hospital days that are used in a year for each thousand enclosed lives. The formula used to determine days per thousand is as follows: (# of days/member months) x (1000 members) x (# of months). An indicator calculated by enchanting the total number of days or visits received by a specific group for a specific period of time. A measure used to evaluate use management performance.

Back to top

Day Outlier - A patient with an abnormally long length of stay compared with other patients in a particular diagnosis related group.

Back to top

Decedents - Afforded privacy rights under the HIPAA Privacy Rule, even though not considered human subjects confined under the Common Rule. As is the current practice, all research protocols relating the review of medical records of deceased subjects or of living and deceased subjects need review and approval by the HRC/IRB and can be conducted without informed permission and authorization only if the protocols satisfy the criteria for a waiver.

Back to top

Decision Support Systems - Computer technologies used in healthcare that consent to providers to collect and analyze data in more complicated and complex ways. Activities supported are including case mix, budgeting, cost accounting, clinical protocols and pathways, outcomes, and actuarial analysis.

Back to top

Deductibles - Amounts essential to be paid by the insured under a health insurance contract, before benefits become payable. Different mechanism of a health plan may have separate deductibles.

Back to top

Deductible Carry Over Credit - Charge incurred through the last three months of a year that may be useful to the deductible and which may be carried over into the next year.

Back to top

Defensive Medicine - Doctors in recent years have admitted to and have been accused to prescribe additional tests or procedures to justify their care, strengthen support for their decisions or simply to confirm their diagnosis. Defensive medicine is said to be one of the main causes of the increasing cost of health care. However, patient groups and patient advocates, not in support of tort reform, explain that the right to sue for malpractice is a valid method of holding physicians responsible for mistakes made.

Back to top

Defined Care - An umbrella term used for Defined Contribution, Consumer-Driven and Self-Directed health plan preparations and other consumer-centered initiatives.

Back to top

Defined Contribution Coverage - A payment procedure for procurement of health benefit plans whereby employers add a specific dollar amount toward the costs of insurance coverage for their employees. Sometimes this includes an indeterminate expectation of guarantee of the specific benefits to be covered.

Back to top

Defined Contribution Health Plan - Health Plans that occupy employer funding of a fixed dollar amount for health benefits, which employees may then use to purchase reimbursement from an employer arranged funding mechanism. The benefits could also be group benefits packaged and arranged by the employer, or purchased individually by the employees.

Back to top

Deidentified- Under the HIPAA Privacy Rule, data are Deidentified by an experienced expert determines that the risk that positive information could be used to identify an individual is very small and documents and justifies the purpose, or by the data do not include any of the subsequent eighteen identifiers which could be used alone or in grouping with other information to identify the subject such as names, geographic subdivisions smaller than a state, all elements of dates except year, telephone numbers, FAX numbers, email address, Social Security numbers, medical record numbers, health plan beneficiary numbers, account numbers, certificate/license numbers, vehicle identifiers including license plates, device identifiers and serial numbers.

Back to top

Dental Health Maintenance Organization (DHMO) - An organization that provides dental services throughout a network of providers to its members in exchange for some form of prepayment.

Back to top

Dental POS - A dental service plan that allows a member to use either a DHMO network dentist or to search for care from a dentist not in the HMO network. Members decide in-network care or out-of-network care at the time they create their dental appointment and usually incur higher out-of-pocket costs for out-of-network care.

Back to top

Dental PPO - An organization that provides dental care to its members throughout a network of dentists who offer discounted fees to the plan members.

Back to top

Department of Health and Human Services (DHHS) - The federal agency that oversees Medicare, Medicaid and other federal health care program.

Back to top

Department of Justice (DOJ) - The federal agency that enforce the law and handles criminal investigations. As the nation's largest law firm, the DOJ protects citizens through effectual law enforcement, crime prevention and crime detection. It is the agency that prosecutes those in the health care system guilty of proven fraudulent action.

Back to top

Dependent - Person roofed by someone else's health plan. In a payer's policy of insurance, a person other than the subscriber qualified to receive care because of a subscriber's contract.

Back to top

Designated Mental Health Provider - Person or place certified by a health plan to provide or suggest appropriate mental health and substance abuse care.

Back to top

Designated Record Set - A health care provider's medicinal and billing records about individuals and any records used by the provider to make decisions about individuals. Individuals, as well as research subjects, have the right under the HIPAA Privacy Rule to access and adjust protected health information in a Designated Record Set.

Back to top

Diagnosis Related Groups (DRG) - An inpatient or hospital classification system used to reimburse a hospital or other provider for their services and to categorize illness by diagnosis and treatment. A categorization scheme used by Medicare that clusters patients into 468 categories on the source of patients' illnesses, diseases and medical problems. Used under Medicare's potential payment system to reimburse inpatient hospitals, regardless of the cost to the hospital to provide services.

Back to top

Diagnostic and Treatment Codes - Particular codes that consist of a brief, specific description of each diagnosis or treatment and a number used to recognize each diagnosis and treatment.

Back to top

Direct Contracting - Providing health services to members of a health plan by a collection of providers contracting directly with an employer, thereby butting out the middleman or third party insurance hauler. This can be provider heaven, since middleman-MCO-is cut out and provider gets some piece of the money usually made by it. Key is to price services properly, since provider is usually at full risk in this situation.

Back to top

Directly Identifiable Health Information - The information that includes personal identifiers. To decide what data may be considered identifiable, please see items that must be detached under the definition of Deidentified.

Back to top

Direct Payment Subscriber - A person enrolled in a prepayment plan that makes individual best payments directly to the plan rather than through a group. Rates of payment are generally higher, and benefits may not be as wide as for the subscriber enrolled and paying as a member of the group.

Back to top

Disallowance- When a payer declines to pay for all or branch of a claim submitted for payment.

Back to top

Discharge Planning - Essential by Medicare and JCAHO for all hospital patients. A process where aftercare services are determined for after discharge from the inpatient facility.

Back to top

Disclosure - Refers to the free of identifiable health information, regarding a patient or patient(s). Disclosure involves the release of information to anyone or any entity outer of the covered entity.

Back to top

Discounted Fee-For-Service - A financial repayment system whereby a provider agrees to supply services on an FFS basis, but with the fees low-priced by a certain percentage from the physician's usual and customary charges. An agreed upon rate for service between the provider and payer that is usually fewer than the provider's full fee. This may be a fixed amount per service, or a proportion discount. Providers generally agree to such contracts because they represent a means to increase their volume or decrease their chances of losing volume.

Back to top

Disease Management - A coordinated system of preventive, diagnostic, and therapeutic events intended to provide cost-effective, quality healthcare for a patient population who have or are at risk for a precise chronic illness or medical condition.

Back to top

Disenrollment- The process or end result of an execution of coverage. Voluntary termination would comprise a member quitting because he or she simply wants out. Involuntary termination would include leaving the plan because of altering jobs. A rare and serious form of involuntary disenrollment is when the illustration terminates a member's coverage against the member's will. This is usually only allowable for gross offenses such as fraud, abuse, nonpayment of premium or copayments, or a demonstrated incapacity to comply with recommended treatment plans.

Back to top

Disproportionate Share Adjustment - A payment adjustment under Medicare's PPS for Medicaid use at hospitals that serve a comparatively large volume of low-income patients, pregnant patients or other patients under the Medicaid program. DSH is a method whereby the government recognizes that hospitals treating high percentages of Medicaid payments would not be capable to cover their costs and remain in service without additional government subsidy.

Back to top

Drug Categories - Groupings that imitate therapeutic uses of drugs based on the International Classification of Diseases diagnostic codes. For instance, drugs may belong to the analgesic category or the antiparkinson category. Categories may also be based on an organ system, such as the cardiovascular group. These guidelines are to be used by prescription drug plans in raising their formularies for the Medicare population. The USP defined 41 therapeutic categories, 32 of which are further separated into pharmacologic classes.

Back to top

Drug Classes - Classes are subcomponents of drug categories and are based either on the chemical structure of the drug or on its device of action. For example, the analgesic group, or drugs which treat pain, is broken down into two classes' opioids and non-opioids. Certain programs are subdivided into an additional level of specificity. For example, the beta-adrenergic blocking agent class of the cardiovascular category, or drugs used to treat hypertension, is subdivided into alpha-beta-adrenergic blocking agents, cardioselective beta-adrenergic blocking agents and nonselective beta-adrenergic blocking agent.

Back to top

Drug Formulary - Varying lists of instruction drugs approved by a given health plan for distribution to a covered person through specific pharmacies. Health plans often confine or limit the type and number of medicines allowed for reimbursement by limiting the drug formulary list. The list of prescription drugs for which a meticulous employer or State Medicaid program will pay.

Back to top

Drug List - A directory of drugs covered by a plan. This is also called a formulary.

Back to top

Drug Plan - When people join a Prescription Drug Plan, they use the plan member cards that are received from the plans when they go to the pharmacies to purchase prescription. When they use their cards, they will usually get discounts on their prescriptions.

Back to top

Drug Risk Sharing Arrangements - Provider organizations may be at limited, full or no risk for drug costs. Providers at fractional risk share in the proportion of savings and / or cost overruns. Groups at full risk understand all the savings or absorb all of the losses. Groups at no risk attract none of the profits or losses. These arrangements are normally made between HMOs and providers in the HMO's attempt to depress the overuse of drugs that will cause a loss of profit for the HMO.

Back to top

Drug Utilization Review (DUR) - Review of an insured population's drug use with the goal of determining how to reduce the cost of utilization. Reviews often result in recommendation to practitioners, including generic substitutions, use of formularies, use of copayments for prescriptions and education. In some cases, practitioners are now penalized or satisfied depending on their drug prescription related costs and utilization. Some consider that these incentives can adversely effect doctor decisions.

Back to top

Dual Choice (Multiple Choice, Dual Option, DC) - Requirements in the HMO Act of 1973 that required employers that offered healthcare coverage to more than 25 employees to recommend a choice of traditional indemnity coverage or managed healthcare coverage under either a closed-panel HMO or an open-panel HMO. Section 1310 of the HMO Act provide for dual choice. Many states also have legislated mandates concerning choices offered within employer packages.

Back to top

Dual Eligible - A Medicare beneficiary who also receives the full variety of Medicaid benefits offered in his or her state. Medicare usually pays the charges for inpatient while Medicaid will reimburse the co-pay for inpatient care in hospitals. Medicare will be measured the primary insurer for inpatient care for the Care/Caid patient.

Back to top

Duplicate Coverage Inquiry (DCI) - Method used by an insurance company or group medical plan to ask about the existing coverage of another insurance company or group medical plan.

Back to top

Duplication of Benefits - When a person is covered under two or more health strategy with the same or similar coverage.

Back to top

Durable Medical Equipment (DME) - Items of medical equipment owned or rented which are located in the home of an insured to facilitate treatment and/or rehabilitation. DME usually consist of items that can withstand repeated use. DME is primarily and regularly used to serve a medical purpose and is usually not useful to a person in the absence of illness or injury. DME is salaried for under both Medicare Part B and Part A for home health services.

Back to top

Durable Medical Equipment Regional Carrier (DMERC) - A private company that agreement with Medicare to pay bills for durable medical equipment.

Back to top