Abuse A pattern of practice that is inconsistent with sound fiscal, business or health service practices, and that results in unnecessary costs to Medica or in reimbursement for services not medically necessary, or that fails to meet professionally recognized standards for health services.
Accessibility The ease with which an eligible member may obtain available services through a managed care organization.
Accreditation One form of external review. In the realm of health care, accreditation generally means that a delivery system has met certain established standards that represent an acceptable level of performance. Accreditation of a health care system is considered by many to be a seal of approval on which purchasers and consumers can base decisions.
Adjustment A method to correct claim reimbursement processing errors, or to incorporate late credits/charges.
Administrative Cost Costs incurred by a carrier, such as an insurance company or HMO, for administrative services such as claim processing, billing, enrollment and overhead.
Admission The admittance of a member to a hospital, skilled nursing facility or licensed acute care facility for a period of not less than 24 hours.
Agreement
The signed Medica Participation Agreement, including any addenda, appendices, exhibits and attachments, the Medica Administrative Manual, the Credentialing Plan and the provider’s application for participation constitute the entire agreement between Medica and the provider. All such individual elements of the agreement are subject to amendment as provided in the Medica Participation Agreement.
Alternative Care Home health care, home IV therapy or other medical services arranged as an alternative to, or in lieu of, hospital inpatient care or outpatient facility care.
Appropriateness Measures whether or not a particular provided service is indicated in the care of a given patient or whether a needed service has not been provided. Of particular importance are diagnostic procedures, medications and therapeutic procedures.
Availability The degree to which the appropriate care/intervention is available to meet the needs of the member.
Average Length of Stay (ALOS) Average number of days in a hospital for each admission.
Return to top.
Benefit Document A plan of health care coverage, issued by Medica for each Medica product, that contains the terms and conditions of a member’s coverage. Also referred to as a “benefit plan” with self-insured plans.
Return to top.
CMS See Centers for Medicare & Medicaid Services.
CMS-1500 (formerly HCFA-1500) A universal form for health care providers to submit claims to health carriers.
Capitation A type of risk-sharing reimbursement method whereby providers in a health plan’s network receive fixed periodic reimbursements (usually monthly) for health services rendered to plan members. Capitated fees are set by contract between a health plan and health care
providers to be reimbursed on a per-person basis, usually with adjustments for age, sex and family size, regardless of the amount of services rendered or costs incurred. The health plan may set aside a percentage of the total annual capitation reimbursement in a
risk pool to safeguard against unexpected costs. At the end of the year, any money left in the risk pool is returned to the providers.
Care Coordination Coordination of all health care, dental care and social needs for a Medica DUAL Solution™ (MSHO demonstration product) member.
Care Management Review and management of health services to determine that they are medically appropriate for members’ needs.
Care System An entity that Medica contracts with at full risk to provide for and coordinate all health care needs for a member enrolled in Medica DUAL Solution™.
Carrier
An organization that has entered into a contract with the Centers for Medicare & Medicaid Services (CMS) to process Medicare claims for physicians’ services, outpatient hospital services, durable medical equipment, and services and supplies not covered by the hospital insurance (Part A) of Medicare.
Case Management Methodology used to ensure that the highest quality, most efficient care is provided to members and across a continuum of care, services and time.
Centers for Medicare & Medicaid Services (CMS) The federal agency responsible for administering Medicare and overseeing states’ administration of Medicaid.
Child & Teen Checkups (C&TC) The name of Minnesota’s Early Periodic Screening, Diagnosis and Treatment (EPSDT) Program. EPSDT is a federally mandated program to provide comprehensive screenings to Medicaid recipients under age 21. Medica is required to provide C&TC screenings to its Medica Choice Care and Medica MinnesotaCare members through its contract with the Minnesota Department of Human Services. C&TC screenings include physical and oral exams, vision and hearing evaluations, developmental screenings and immunizations.
Childhood Asthma Program A referral program consisting of three to six home health care visits by a registered nurse to educate pediatric asthma members and their families about triggers, appropriate medication, peak flow meter use and self-management of the disease.
Claim An invoice, bill or itemized statement for services provided to a member.
Clinical Practice Guidelines
Systematically developed statements to assist providers and members with appropriate health care decisions for specific clinical circumstances.
Clinical Quality Clinical quality has two components:
- Technical: The skill and competence of people, and the systems, procedures and equipment that perform reliably and effectively in a way that is quantifiable.
- Experiential: The subjective experience of the healing relationship that is developed through the member’s interactions with the provider and the environment in which care and services are provided.
Complaint A verbal or written expression of dissatisfaction by a member or participating provider.
Consultation A circumscribed diagnostic or management opinion requested of a specialist physician by another physician. It includes the implicit or explicit expectation that care will be returned to the referring physician after the consultation is completed.
Continuity of Care If Medica terminates its contract with a provider without cause, or if a member’s employer changes health plans and the member’s current provider is not a network provider, the member may be able to continue care with that provider and be eligible for in-network benefits.
Coordination of Benefits (COB) A provision applicable when a member is covered under more than one health plan. It requires coordination of the reimbursement of benefits by all plans to eliminate overinsurance or duplication of benefits.
Copayment or Coinsurance The amount a member is required to pay for certain health services in accordance with the member’s benefit document.
Cosmetic
Services and procedures that improve physical appearance but do not correct or improve a physiological function and are not determined to be medically necessary.
Credentialing The process focused on verification of adequate training, experience, licensure and competence, and the assessment of the data and information collected to determine if an individual or organizational provider is qualified and competent to render acceptable quality
of care to Medica members. The credentialing process with qualification criteria is set forth in the Credentialing Plan established by the Medica board of directors. All actions related to acceptance, denial, discipline and termination of participation status of a provider are governed by the Credentialing Plan. The board has ultimate responsibility and authority for all credentialing actions.
Credentialing Subcommittee Reviews providers’ compliance with the professional criteria of the Credentialing Plan. Makes decisions regarding acceptance and/or continuance as a Medica participating provider.
Current Procedural Terminology (CPT-4) A listing of descriptive terms and identifying codes for reporting medical services and procedures.
Customary Charge
The usual fees charged by a health care provider.
Customers Parties who receive and pay for services. These include consumers, employer purchasers and public sector purchasers.
Return to top.
Back to Previous.