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Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) - A Medicaid program for recipient younger than 21 that provides screening, vision, hearing, and dental services at intervals that meet accepted standards of medical and dental practices and at other intervals as necessary to decide the survival of physical or mental illnesses or conditions.

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Economic Credentialing - The use of economic criterion unrelated to quality of care or professional competency in determining an individual's qualifications for initial or enduring hospital medical staff membership or privileges. Economic credentialing has become a contentious topic involving much concern about ethics. Other forms of control comprise utilization review, certification, exclusive provider panels and more.

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EDI Translator - Used in electronic claims and medical record transmissions, this is a software tool for cooperative an EDI transmission and converting the data into another format, or for converting a non-EDI data file into an EDI format for transmission.

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Edits - Criteria that, if unmet, will cause an automatic claims dispensation system to "kick out" a claim for further investigation.

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Effective Date - The date on which a policy's coverage of a menace goes into effect.

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Election - An enrollee's choice to join or leave a health plan.

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Electronic Claim - A digital demonstration of a medical bill generated by a provider or by the provider's billing agent for compliance using telecommunications to a health insurance payer.

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Electronic Data Interchange (EDI) - The automated exchange of data and credentials in a standardized format. In health care, some common uses of this technology comprise claims submission and payment, eligibility, and referral authorization.

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Electronic Media Claims - A flat file arrangement used to transmit or transport claims, such as the 192-byte UB-92 Institutional EMC format and the 320-byte Professional EMC NSF.

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Electronic Medical Record (EMR) - A computer-based certification containing health care information. This technology, when fully developed, meets provider wants for real-time data access and evaluation in medical care. Together with clinical workstations and clinical data depository technologies, the EMR provides the mechanism for longitudinal data storage and access. A motivation for healthcare entity to implement this technology derives from the need for medical outcome studies, more efficient care, speedier statement among providers and management of health plans.

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Electronic Remittance Advice - Any of several electronic formats for explaining the expenditure of health care claims.

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Eligible Dependent - Person permitted to receive health benefits from someone else's plan.

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Eligible Employee - Employee who qualifies to collect benefits.

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Eligible Expenses - Charges covered below a health plan.

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Eligibility Guarantee - In the Medicaid managed care and Family Health Plus programs, the stipulation by which Members may remain enrolled for the balance of their initial six months of conscription even if they lose Medicaid or Family Health Plus eligibility.

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Eligible Person - Person who meets the qualifications of a health plan agreement.

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Elimination Period - Most often used to assign the waiting period in a health insurance policy.

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Emergency - Sudden unpredicted onset of illness or injury which requires the immediate care and attention of a qualified physician, and which, if not treated instantly, would jeopardize or impair the health of the Member, as determined by the payer's Medical Staff. Significant in that Emergency may be the only satisfactory reason for admission without pre-certification.

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Emergency Center, Emergi-center - Non-hospital affiliated health facility that provides short-term care for minor medical emergency or procedures needing immediate treatment also called urgi-center, urgent center or free standing emergency medical service center.

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Emergency Medical Treatment and Labor Act (EMTALA) - An act pertaining to urgent situation medical situations. EMTALA requires hospitals to provide emergency action to individuals, regardless of insurance status and capacity to pay.

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Employee Assistance Program (EAP) - A service, plan or set of profits that are designed for personal or family problems, together with mental health, substance abuse, gambling addiction, marital problems, parenting problems, emotional problems or financial pressures. This is frequently a service provided by an employer to the employees, designed to help employees in getting help for these troubles so that they may remain on the job. It is sometimes implemented with a disciplinary program that requires that the impaired employee participate in EAP in order to keep employment.

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Employee Retirement Income Security Act of 1974 (ERISA) - Also called the Pension Reform Act, this act regulates the bulk of private pension and welfare group benefit strategy in the U.S. It sets forth necessities governing, among many areas, participation, crediting of service, vesting, communication and disclosure, funding, and fiduciary conduct. ERISA exempts most large self-funded plans from State regulation and, hence, from any change activities undertaken at state level, which is now the arena for sustained healthcare reform.

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Employer Mandate - Under the Federal HMO Act, describes situation when federally qualified HMOs can mandate or require an employer to suggest at least one federally qualified HMO plan of each type. Option that federally qualified HMOs have to exercise over employees, requiring them to have obtainable one or more types of HMOs per plan.

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Employment Model IDS - An incorporated delivery system that generally owns or is affiliated with a hospital and establish or purchases physician practices and retains the physicians as employees.

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Encounter - A contact between an individual and the health care scheme for a health care service or set of services related to one or more medical conditions.

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Encounter Data - Data involving to treatment or service rendered by a provider to a patient, regardless of whether the provider was reimbursed on a capitated or fee-for-service basis.

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Encounter Report - A report that supply management information about services provided each time a patient visits a provider.

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Enrolled Group - Persons with the same employer or with membership in an organization in common, who are enrolled jointly in a health plan. Often, there are conditions regarding the minimum size of the group and the minimum percentage of the group that must register before the coverage is available.

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Enrollee - Any person qualified as either a subscriber or a dependent for service in accordance with a contract. The same as beneficiary, individual, or associate of a health plan.

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Enrollment - Initial process whereby new individuals relate and are accepted as members of a prepayment plan. The total number of enclosed persons in a health plan. Also refers to the procedure by which a health plan enrolls groups and individuals for membership or the number of enrollees who sign up in any one group.

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Enrollment Area - The geographic region in which the health plan may enroll Members.

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Enrollment and Payment System (EPS) - A term used to cover the entire health plan or partner company activities involved in developing and administering its various aspects such as enrollment, payments, appeals, etc.

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Episode of Care - A term used to describe and calculate the various health care services and encounters rendered in connection with identified injury or period of illness.

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Essential Community Providers - Providers such as community health centers that have traditionally serve low-income populations.

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Ethics in Patient Referrals Act - A centralized act which, along with its amendments, prohibits a physician from referring patients to laboratories, radiology services, diagnostic services, physical therapy services, home health services, pharmacies, occupational therapy services, and suppliers of tough medical equipment in which the physician has a financial interest.

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Evidence-based Medicine - Evidence-based health care is the careful use of current best evidence in making decisions about the care of individual patients or the release of health services. Term used in quality improvement and gaze review programs in hospitals and health plans.

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Evidence or Explanation of Coverage (EOC) - A booklet provided by the carrier to the insured abbreviation benefits under an insurance plan.

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Evidence of Insurability - Proof of a person's physical condition that property acceptability for insurance or a health care contract.

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Exceptions Process - A path of action that allows patients to challenge the placement of a drug on a higher-cost tier or the exclusion of a particular drug from their formulary. Under the Prescription Drug Benefit, an exceptions process must be included into both stand-alone prescription drug plans (PDP) and those that are part of a Medicare Advantage plan (MA-PD). Enrollees are able to demand that a formulary drug be provided at a lower tier for cost-sharing or that a non-formulary drug be provided by the plan.

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Excess Charges - Used by CMS to describe in the Medicare Plan the difference between a health care provider's actual charge and the Medicare-approved payment amount.

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Excluded Hospitals and Distinct-Part Units - Hospitals and hospital units that are specially excluded from Medicare's prospective pay system. These usually include children's, cancer, hospital based outpatient care, long-term care, rehabilitation inpatient and psychiatric hospitals or units. Rehabilitation or psychiatric units of sensitive care hospitals are exempt if they meet certain criteria particular by HHS and are referred to as "DRG exempted".

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Exclusions - Conditions or situations not careful covered under contract or plan. Clauses in an insurance agreement that deny coverage for select individuals, groups, locations, properties or risks. Providers will discuss for exclusions for outliers and carve-out of certain high cost procedures, while payers will negotiate for exclusions to avoid payment of higher cost care.

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Exclusive Provider Arrangement (EPA) - A protection or service plan that provides benefits only if care is rendered by the institutional and professional providers with which it contracts.

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Exclusive Provider Organization (EPO) - A plan that limits coverage of non-emergency care to constricted health care providers. Operates similar to an HMO plan but is usually offered as an insured or self-funded product. Sometimes looks like a managed care organization that is organized equally to a PPO in that physicians do not receive capitated payments, but the plan only allows patients to prefer medical care from network providers.

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Exclusivity Clause - A part of a agreement which prohibits physicians, providers or other care entities from contracting with more than one managed care organization. Exclusive contracts are frequent in staff model HMOs and IPAs but becoming less common in other health plan contracting.

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Expansion - Some HMOs compute Plan growth as part of the capitation rate in order to provide the necessary capital for growth.

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Expedited Organization Determination - A quick decision from a Medicare+Choice organization about whether it will provide a health service. A beneficiary may receive a fast decision within 72 hours when life, health or capacity to regain function may be jeopardized.

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Experience - A term used to describe the relationship of premium to claims for a plan, coverage, or benefits for a stated time period it is usually expressed as a ratio or percent.

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Experience Rating - The process of setting rates moderately or in whole on evaluating previous claims experience for a specific group or pool of groups. The ranking system by which the Plan determines the capitation rate or premium rate is resolute by the experience of the individual group enrolled, based on actual or anticipated health care use by the specific group of insureds. Each group will have a dissimilar rate based on utilization.

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Experience-Rated Premium - A premium with is based upon the predictable claims experience of or utilization of service by, a contract group according to its age, sex, constitution, and any other attributes expected to affect its health service utilization, and which is topic to periodic adjustment in line with actual claims or utilization experience.

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Explanation of Benefits (EOB) - A declaration sent to covered individuals explaining services provided, amount to be billed, and payments made. A synopsis of benefits provided subscribers by the carrier.

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Extended Care Facility (ECF) - A nursing, long-term, or recuperative home offering skilled nursing care and rehabilitation services on a 24-hour basis.

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External Quality Review Organization (EQRO) - States are necessary to contract with an entity that is external to and independent of the State and its HMO and HIO contractor to perform an annual appraisal of the quality of services furnished by each HMO or HIO contractor.

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