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Glossary

  1. A

    accreditation
    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.
  2. B

    behavioral healthcare
    The provision of mental health and chemical dependency (or substance abuse) services.
    Benchmarking
    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.
  3. C

    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).
  4. D

    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.
  5. E

    electronic medical record (EMR)
    A computerized record of a patient's clinical, demographic and administrative data. Also known as a computer-based patient record.
  6. M

    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.
  7. P

    parent company
    A company that owns another company.
    pooling
    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.
  8. S

    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. .
  9. U

    unbundling
    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.