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A
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J
J-Codes - A subset of the HCPCS Level II code set with a high-order value of "J" that has been used to recognize certain drugs and other items.
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Job-Lock - Laws have now been enacted by congress which includes continuation of benefits (COBRA) and other requirements which eliminate pre-existing clauses for those individuals who change coverage plans but have maintained continuance of coverage in general. The inability of individuals to alter jobs because they would lose crucial health benefits.
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Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) - Previously called JCAH or Joint Commission on Accreditation of Hospitals, this is the examine review organization which provides the primary review of hospitals and healthcare providers. Many insurance companies require providers to have this certification in order to seek 3rd party payment, although, many small hospitals cannot afford the cost of accreditation.
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Joint Venture - A type of partial structural integration in which one or more part organizations combine resources to achieve a stated objective. For example, independent practice associations can split ownership of a venture and responsibility for its operations, but still maintain separate ownership and control over their operations outside of the joint venture.
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Justice or Equity - An moral principle, which, when applied to managed care, states that managed care organizations and their providers allocate resources in a way that fairly distributes benefits and burdens among the members.
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K
Key Contributor Plan - This refers to a little known performance-based program with incentives for the reason of attracting, motivating and retaining key individuals or small groups.
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L
Large Claim Pooling - System that isolates claims over a certain level and charges them to a pool funded by charges of all groups who share the pool. Considered to help stabilize significant premium fluctuations.
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Large Group - A large pool of individuals for which health coverage is provided by the group support. A large group may be distinct as more than 250, 500, 1,000, or some other number of members, depending on the MCO.
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Large Local Groups - Accounts that agreement on a local basis for group employee health benefits.
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Large Urban Area - An urban geometric region with population of one million or more.
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Legacy Systems - Computer applications, both hardware and software, which have been inborn through previous acquisition and installation. Most often, these systems run business applications that are not included with each other. Newer systems which stress open design and dispersed processing capacity are gradually replacing such systems. This term is used often in discussing HIPAA and its computing requirements.
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Legend Drug - Drug that the law says can only be obtained by instruction.
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Length of Stay (LOS) - The duration of an event of care for a covered person. The number of days an individual stays in a hospital or inpatient ability.
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Licensing - A procedure most States employ, which involves the review and approval of applications from HMOs prior to beginning operation in certain areas of the State. Areas examined by the licensing authority which includes fiscal soundness, network capacity, MIS, and quality assurance. The applicant must show it can meet all existing statutory and regulatory requirements prior to beginning operations.
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Lifetime Limit - A limit on the benefits paid under a policy. For example, many policies have a lifetime limit of $1 million, which means that the insurer agrees to wrap up to $1 million in covered services over the life of the policy.
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Lifetime Maximum Benefit - The maximum amount a health plan will pay in benefits to an insured individual.
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Lifetime Reserve Days - In the Original Medicare Plan, a total of 60 additional days that Medicare will pay for when an enrollee is in a hospital more than 90 days during a benefit period. Once these 60 reserve days are used, the citizen does not obtain any more extra days during his or her lifetime. For each lifetime reserve day, Medicare pays all covered costs apart from a daily coinsurance.
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Limitations - A restriction on the amount of benefits paid out for a particular covered expense.
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Limited Data Set - Under HIPAA, this expression refers to a set of data that may be used for research, public health or health care operations without an approval or waiver of authorization. A covered entity must penetrate into a data use agreement with the recipient of a limited data set. It should be noted that even though a limited data set is subject to only to choose provisions of the HIPAA Privacy Rule, it may be covered by the Common Rule.
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Limiting Charge - The maximum amount that a non-participating physician is allowable to charge a Medicare beneficiary for a particularly defined procedure or bundled service. These limits are available by the individual state intermediaries for Medicare and CMS and are usually combined in reports with the allowed charges and regional payment schedules. In 1993, the limiting charge was placed at 115 percent of the Medicare-allowed charge.
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Local Access Transport Area (LATA) - A definite region in which a telephone and long distance carrier operates. Important idea for those CHINs that depend upon phone lines. When creating communications networks, you try to avoid crossing boundaries of these, if possible, since costs rise dramatically when there is a need to communicate over more than one LATA.
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Local Codes - A generic word for code values that are defined for a State or other local division or for a specific payer. Commonly used to explain HCPCS Level III Codes.
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Local Exchange Carrier (LEC) - The telephone company that provides and supports the local association to the public switched telephone network. In a lot of areas of the US, the LEC is one of the seven regional Bell operating companies (RBOCs) or "Baby Bells," although these companies are undergoing dramatic mergers now. These LECs become partners for organizations looking to develop a CHIN or, more conservatively, simply seeking to integrate their information system across many sites within a region.
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Lock-in - A contractual provision by which members are necessary to use certain health care providers in order to receive coverage.
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Long-term Care (LTC) - A set of health care, personal care and social services required by persons who have lost, or never acquired, some degree of useful capacity in an institution or at home, on a long-term basis. Long-term care can be provided at home, in the community, or in various types of services, including nursing homes and assisted living facilities. Ambulatory services such as home health care which can also be providing on a long-term basis are seen as alternatives to long-term institutional care.
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Long-term Care Insurance - Insurance planned to pay for some or all of the costs of long term care.
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Long-Term Disability (LTD) - Insurance which pays employees a percentage of monthly earnings in the event of disability.
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Loss Rate - The number and timing of losses that will occur in a given group of insured's while the coverage is in force.
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Loss Ratio - Incurred claims plus expenses, separated by paid premiums.
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