- An evaluative process in which a healthcare organization undergoes an examination of its operating procedures to determine whether the procedures meet designated criteria as defined by the accrediting body, and to ensure that the organization meets a specified level of quality.
- ambulatory care facility (ACF)
- A medical care center that provides a wide range of healthcare services, including preventive care, acute care, surgery, and outpatient care, in a centralized facility. Also known as a medical clinic or medical center.
- ancillary services
- Auxiliary or supplemental services, such as diagnostic services, home health services, physical therapy and occupational therapy, used to support diagnosis and treatment of a patient's condition.
- behavioral healthcare
- The provision of mental health and chemical dependency (or substance abuse) services.
- A method of planning and implementing quality management programs that consists of identifying the best practices and best outcomes for a specific process and emulating the best practices to equal or surpass the best outcomes.
- Call abandonment rate
- A measure of how often members hang up before receiving assistance when they make telephone calls to a company and are put on hold.
- clinic without walls
- See group practice without walls.
- clinical practice guideline
- A utilization and quality management mechanism designed to aid providers in making decisions about the most appropriate course of treatment for a specific clinical case.
- coordinated care plans (CCPs)
- The Medicare+Choice delivery option that includes HMOs (with or without a point-of-service component), preferred provider organizations (PPOs), and provider-sponsored organizations (PSOs).
- dental health maintenance organization (DHMO)
An organization that provides dental services through a network of providers to its members in exchange for some form of prepayment. For all of your dental questions and/or claim forms, please contact your local Blue Cross and Blue Shield company.
- disease management
- A coordinated system of preventive, diagnostic and therapeutic measures intended to provide cost-effective, quality healthcare for a patient population who have or are at risk for a specific chronic illness or medical condition. Also known as disease state management.
- disease state management
- See disease management.
- electronic medical record (EMR)
- A computerized record of a patient's clinical, demographic and administrative data. Also known as a computer-based patient record.
- medical director
- The health plan physician executive who is responsible for the quality and cost-effectiveness of the medical care delivered by the plan's providers. Also known as a chief medical officer.
- medical underwriting
- The evaluation of health questionnaires submitted by all proposed plan members to determine the insurability of the group.
- member services
- The broad range of activities that an MCO and its employees undertake to support the delivery of the promised benefits to members and to keep members satisfied with the company.
- mutual company
- A company that is owned by its members or policyowners.
- parent company
- A company that owns another company.
- The practice of underwriting a number of small groups as if they constituted one large group.
- prospective review
- The review and possible authorization of proposed treatment plans for a patient before the treatment is implemented.
- screening programs
- Preventive care programs designed to determine if a health condition is present even if a member has not experienced symptoms of the problem. .
- A coding inconsistency that involves separating a procedure into parts and charging for each part rather than using a single code for the entire procedure. The process of identifying and classifying the risk represented by an individual or group.
- underwriting manual
- A document that provides background information about various underwriting impairments and suggests the appropriate action to take if such impairments exist.