| Term | Definition |
|---|---|
| Access |
a patient's ability to obtain medical care, which is influenced by a number of variables such as the availability of services, acceptability to the patient, location of facilities, transportation, hours of operation, and availability of insurance cove
|
| Acute care |
medical care that usually requires active intervention by a medical
practitioner for a person with a single episode of short-term illness
or with an exacerbation of a chronic condition
|
| Administrative costs |
those specific costs incurred for billing, claims, membership, accounting, and other general overhead functions
|
| Allowable charge |
the maximum fee or cost for a service rendered or supplies furnished by
health providers that qualify for an insurance reimbursement
|
| Alternative health care |
term that referred to any other choice for health coverage other than
traditional fee-for-service; often this term was applied to managed
care, which is now considered mainstream health care
|
| Alternative medicine |
therapies and practices outside of the mainstream of traditionally accepted medical practice
|
| Ancillary services |
services other than professional services, such as x-ray, laboratory, and/or anesthesia, etc.
|
| Assignment of Benefits |
method by which a patient/claimant assigns his or her benefits under a
claim to be paid to some designated person or organization, usually a
physician or a hospital, allowing them to collect the insurance
benefits directly from the carrier
|
| Authorization |
as it applies to managed care, authorization is the approval of care, such as hospitalization
|
| Balance billing |
provider's billing of a covered person for charges above the amount
reimbursed by the health plan, i.e., the difference between the billed
charges and the amount paid, or the fee amount remaining after patient
copayments
|
| Beneficiary |
person designated by an insuring organization as eligible to receive insurance benefits
|
| Board certified |
means a physician has passed the national examination in a particular
field such as Internal Medicine, Radiology, or Orthopedic Surgery, etc.
|
| Capitation |
a stipulated dollar amount established to cover the cost of health care
delivered for a person; this term usually refers to a negotiated per
capita rate to be paid periodically, usually monthly, to a health care
provider; the provider is responsible fo
|
| Carrier |
an insurance company or health plan that has some financial risk or that manages health care benefits
|
| Case Management |
a system that insurance companies and managed care plans use to ensure
that individuals receive appropriate, timely, and reasonable health
care services; the case manager coordinates all care, including
specialists, hospitals, tests, etc.
|