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Gag Clause - A provision of an agreement between a managed care organization and a health care provider that restricts the amount of information a provider may split with a beneficiary or that limits the conditions under which a provider may recommend a specific treatment option.
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Gatekeeper - A primary care physician, utilization review, casing management, local agency or managed care entity accountable for determining when and what services a patient can access and receive recompense for. In HMOs, it is commonly an arrangement, in which a primary care provider serves as the patient's agent, arranges for and coordinates suitable medical care and other necessary and appropriate referrals. The term gatekeeper is also used in health care business to explain anyone that makes the decision of where a patient will receive services.
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Gatekeeping - The process by which a gatekeeper makes the assessment where a patient will receive services. In managed care, gatekeeping can also refer to the UR process of referrals and procedures that must first be preauthorized by an agent of the MCO excluding in cases of emergency care.
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Generic Drug or Generic Equivalent - A drug which is exactly the same as a variety name drug and which may be manufactured and marketed after the brand name drug's patent expires. Generic drugs cost considerably less than brand name drugs, and are identical in terms of efficacy, safety, side effect profile, and dosing.
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Generic Substitution - Substituting a general drug for an identical brand-name drug that has lost its patent protection. Generic replacement lowers drug costs for both consumers and prescription benefit managers while providing equal efficacy, safety, side effect profile and dosing with a few significant exceptions.
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Genetics - The study of how particular qualities are passed from parents to children. Identifiable genetic information receives the similar level of protection as other health care information under the HIPAA Privacy Rule. Of note for genetic researchers, the rule defines "identifiable" information to comprise information from the individual as well as relatives. Thus researchers considering whether to de-identify data should appraisal the definition of de-identified information closely.
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Geographic Availability - The number of primary care providers inside a given radius of a particular target.
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Global Budgeting - Limits located on categories of health spending. A method of hospital cost containment in which participating hospitals must share a prospectively set budget. Method for allocating funds among hospitals may vary but the key is that the participating hospitals agree to a collective cap on revenues that they will receive each year. Global budgeting may also be mandated below a universal health insurance system.
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Global Fee - A total indict for a specific set of services, such as obstetrical services that encompass prenatal, delivery and post-natal care. Managed care organizations will frequently seek contracts with hospitals that contain set global fees for certain sets of services. Outliers and carve-outs will be those services not integrated in the global negotiated rates.
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Guaranteed Issue - Requirement that health plans suggest coverage to all businesses during some period each year.
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Grace Period - Period past the due date of a premium during which treatment may not be cancelled.
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Grievance- An objection by an enrollee regarding the way Medicare or a health plan provides its service. Usually, if an enrollee has a complaint about a treatment decision or a service that is not covered, the enrollee will file an appeal, rather than a grievance.
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Grievance Procedures - The process by which an insured can air complaints and search for remedies.
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Gross Charges Per 1,000 - A pointer calculated by taking the gross charges incurred by a specific group for a specific period of time, dividing it by the average number of enclosed members or lives in that group through the same period, and multiplying the result by 1,000.
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Gross Costs Per 1,000 - A pointer calculated by taking the gross costs incurred for services received by a specific group for a definite period of time, dividing it by the average number of covered members or lives in that group through the same period, and multiplying the result by 1,000. This is calculated in the aggregate and by modality of treatment, e.g. inpatient, residential, partial hospitalization, along with outpatient.
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Group Health Plan - A health plan that provides health coverage to employees, previous employees, and their families, and is supported by an employer, employee organization or other organized group.
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Group Health Plan Number - A number that is given to all group health plans in the future by the CMS division administering the transactions, code sets, security and administrative simplification portions of the Health Insurance Portability and Accountability Act and GSA - General Services Administration.
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Group Insurance - Any insurance policy or health services bond by which groups of employees are covered under a single policy or contract, issued by their employer or other group unit.
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Group Market - A market section that includes groups of two or more people that enter into a group contract with an MCO under which the MCO provides healthcare coverage to the members of the group.
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Group Model HMO, Group Network HMO, Group Practice Model HMO - An HMO that contracts with one or more autonomous group practice to provide services to its members in one or more locations. Health care plan involving contracts with physicians prepared as a partnership, Professional Corporation, or other legal association.
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Group Practice - A group of persons approved to practice medicine in the State, who, as their principal professional activity, and as a group responsibility, engage or undertake to engage in the synchronized practice of their profession primarily in one or more group practice facilities, and who in their association share common overhead expenses if and to the extent such expenses are paid by members of the group, medical and other records, and considerable portions of the equipment and the professional, technical, and administrative staffs.
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Group Practice without Walls (GPWW) - Similar to an independent practice association, this type of physician collection represents a lawful and formal entity where certain services are provided to each physician by the entity, and the physician continues to practice in his/her own ability. It can contain marketing, billing and collection, staffing, management.
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Guaranteed Eligibility - A distinct period of time that all patients enrolled in prepaid health programs are considered eligible for Medicaid, despite of their actual eligibility for Medicaid. A State may relate to CMS for a waiver to incorporate this into their contracts.
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Guaranteed Issue Rights - Rights that senior citizens have in certain situations when insurance companies are required by law to sell or offer those Medigap policies. In this situation, an insurance company can't deny someone a policy, or place conditions on a policy, such as exclusions for pre-existing conditions, and can't indict the citizen more for a policy because of past or present health problems.
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Guaranteed Renewable - A right that an older citizen has that requires an insurance company to automatically renew or continue the citizen's Medigap policy, if not the citizen makes untrue statements to the insurance company, commits fraud or doesn't pay your premiums.
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Guidelines - Clinical practice parameters, guidelines or protocols, usually established authoritative bodies, which detail the procedures appropriate for the physician to use in making a diagnosis and treating it.
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