Glossary Entries
Collection: Managed Care
Actuary
Admissions Per 1,000
Adverse Selection
AHP Accountable Health Plan
Alternate Delivery Systems
Application Integrators
ASO Administrative Services Only
ATM Asynchronous Transfer Mode
Audit of Provider Treatment or Charges
Capitation
Carve-Outs
Case Rate
Character-based Terminal
CHIN Community Health Information Network
Clinic Without Walls (CWW)
Clinical Data Repository
Clinical Decision Support
Clinical or Critical Pathways
Closed Panel
Collections Per 1,000
Community Rating
Computer-based Patient Record (CPR)
Concurrent Review
Continued Stay Review
Cost Shifting
Database Management System ( DBMS)
Days (Or Visits) Per 1,000
Direct Contracting
Discounted Fee-For-Service
Disease Management
DRGs Diagnosis-Related Groups
Drug Utilization Review (DUR)
Electronic Data Interchange (EDI)
Electronic Fund Transfers (EFT)
Enrolled Group
Enrollee
ERISA -- Employee Retirement Income Security Act of 1974
Exclusive Provider Organization (EPO)
Experience
Experience Rating
Fee Schedule
Fee-for-Service
Flat Fee-Per-Case
Formatting and Protocol Standards
Gatekeeper
Gross Charges Per 1,000
Gross Costs Per 1,000
Group Model
GUI Graphical User Interface
HCFA 1500
Health Level Seven (HL7)
HIPC Health Insurance Purchasing Cooperative
HMO Health Maintenance Organization
HPPC Health Plan Purchasing Cooperatives
IBNR Incurred but not Reimbursed
IDS/I(H)DS Integrated (Health) Delivery System
Indemnity Health Insurance
Interface
IPA Independent Physician Association; Individual Practice Association; Independent Provider Association
ISDN Integrated Services Digital Network
LATA Local Access Transport Area
Legacy Systems
Local Exchange Carrier LEC
Managed Behavioral Health Program (MBHP)
Managed Health Care
Master Patient/Member Index
Medically Necessary
MLR Medical Loss Ratio
MSO
Multiple Employer Trust (MET)
Network Model
Object Oriented Database
Out-of-Area Benefits (HMO)
PCP Capitation
PCP Primary Care Provider
PHO Physician-Hospital Organization
PMPM Per Member Per Month
PMPY Per Member Per Year
Point-of-Care Technology
POS Point-of-Service
PPO Preferred Provider Organization
Pre-Certification
Predetermination
Prepaid Group Practice Plan
Profile
Profile Analysis
Provider Organization
PTMPY Per Thousand Members Per Year
Relational Data Model
Resource-Based Relative Value Scale (RBRVS)
Retrospective Review Process
Risk Sharing
Self-Funded Health Plans
Self-insurance
Sub-Capitation
Telnet
TPA Third-Party Administrator
Treatment Episode
UB-92 Uniform Bill 1992
Utilization
Value Added Networks (VANs)
Withhold Pool