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Deductible The annual amount of charges for health services, as provided in the member’s benefit document, that the member is required to pay in advance of any coverage by Medica.
Diagnosis-related Group (DRG) A system of classification for inpatient hospital services based on principal diagnosis, secondary diagnosis, surgical procedures, age, gender and presence of complications. This system of classification is used as a financing mechanism to reimburse hospitals and other selected health care providers for services rendered.
Discharge Planning The evaluation of patients’ medical needs in order to arrange for appropriate care after discharge from an inpatient setting.
Drug Enforcement Administration (DEA)
The federal agency that issues licenses to prescribe and dispense scheduled drugs.
Drug Formulary A list of medications covered for Medica members. Content is determined by Medica’s Pharmacy and Therapeutics Committee, and is based on safety, efficacy and cost. The formulary is reviewed on a regular basis to ensure it remains responsive to the therapeutic needs of members and participating providers.
Go to Medica List of Preferred Drugs (Formulary).
Durable Medical Equipment (DME) Medical equipment that can stand repeated use and is generally used at home.
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Effectiveness The degree to which care/intervention is provided in the correct manner, given the current state of knowledge, in order to achieve the desired outcome(s) for the member. The effectiveness of health care relates to professional and support staffs’ ability to perform in a manner that ensures members achieve the most desirable outcomes. Effectiveness involves minimizing risks to members and documenting members’ health status and the care provided.
Efficiency The ratio of outcomes (results of care/intervention) for a member to the resources used to deliver the care.
Elderly Waiver Services Services that are covered under an MSHO program (Medica DUAL Solution™) that would normally be considered “custodial” in nature. Examples include meals on wheels, adult day care and foster care.
Elderly Waiver Vendor A person/entity who (a) if required is duly licensed, registered or certified in Minnesota, (b) provides goods or services that constitute Elderly Waiver Services, and, (c) is a partner or shareholder in, employed by or under contract with a care system.
Electronically Stored Data Data stored in a typewriter, word processor, computer, existing or pre-existing computer system or computer network, magnetic tape or computer disk.
Eligible Expense The customary charge for health services covered under the member’s benefit document.
Emergency A condition for which a reasonable layperson believes the circumstances require immediate medical care that could not wait until the next working day or next available clinic appointment. A condition that requires immediate treatment to preserve life; prevent serious impairment to bodily functions, organs or parts; or prevent placing physical or mental health in serious jeopardy.
Evaluation The review and assessment of the quality and appropriateness of an important aspect of care for which a pre-established level of performance (threshold for evaluation) has been reached during monitoring of activities.
Explanation of Benefits (EOB) A statement sent to members by Medica listing services provided, amount billed, copayment, coinsurance or deductible, and reimbursement made.
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Facility An entity that provides diagnostic, medical, therapeutic and/or surgical services by or under the direction of physicians and with continuous RN services. This includes but is not limited to hospitals, ambulatory surgical centers and skilled nursing facilities.
Fee-for-service The payment to health care providers for service(s) rendered.
Fee Maximum The maximum fees reimbursable for health services rendered by a participating provider and determined from time to time by Medica. Such fees generally vary for each of the Medica products and may vary to reflect unique characteristics of certain health services.
Fee Schedule A schedule of fee maximums developed by Medica for the purpose of establishing common reimbursement amounts made to participating providers for certain products, procedures and services.
Financial Records Includes written and electronically stored data of a provider who receives payment for a member’s service from Medica.
Foreign Language Interpreter Service A service to help Medica Choice Care, Medica DUAL Solution™ and Medica MinnesotaCare members gain better access to health care. Medica arranges for foreign language interpreter services during office visits with participating providers, at no cost to members.
Fraud Any acts that constitute a crime against Medica or other health care programs, or attempts or conspiracies to commit those crimes.
Function Goal-directed, interrelated series of processes, such as quality assessment and improvement functions.
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Gatekeeper
A designated physician or clinic that provides or coordinates all health care services for a member.
General Assistance Medical Care (GAMC) A state program that provides medical benefits to individuals not eligible for other state or federal programs. State tax dollars pay for GAMC. Medica Choice Care is Medica’s program for GAMC recipients.
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HCFA See Centers for Medicare & Medicaid Services.
HCFA-1500 See CMS-1500.
[this doesn't exist???]Health Care Common Procedure Coding System (HCPCS) A listing of codes and descriptive terminology used for reporting the provision of supplies, materials, injectable drugs and certain medical services to payers, developed by CMS.
Health Maintenance Organization (HMO) An entity that provides, offers or arranges for coverage of designated health services needed by health plan members for a fixed, prepaid premium.
Health Plan Employer Data and Information Set (HEDIS) HEDIS was designed to permit employers to understand what value their health care dollars buy and provide the information necessary to hold a health plan accountable for its performance. HEDIS includes health plan performance measures in quality, access, utilization, satisfaction and finance.
Health Profile A health assessment tool to gather information on members newly enrolled in a Medica health plan. The assessment focuses on four topics:
- Access to health services.
- Current health needs of the member.
- General health history of the member, including family medical history.
- Preventive behavior.
Health Records Any electronically or written stored data, and written or diagrammed documentation of the nature, extent and medical necessity of a health service provided to a Medica member.
Health Services The health care services and supplies provided to a member and covered under the member’s benefit document.
Home Health Care Agency A facility licensed, certified or otherwise authorized, pursuant to state and federal laws, to provide health care services in the home.
Hospice A facility or program licensed, certified or otherwise authorized, pursuant to the law of jurisdiction in which services are received, to provide palliative and supportive care to the terminally ill.
Hospital A facility that provides diagnostic, medical, therapeutic and surgical services by, or under, the direction of physicians and with 24-hour RN services.
Hospital Contingency Reserve (HCR) A fund consisting of amounts deducted from sums otherwise reimbursable to a hospital that are subject to withholding by Medica in Medica’s sole discretion and earned and, as applicable, paid out in the event certain performance standards are met. The amount of HCR withheld and the conditions for earning and pay-out with respect to each Medica product are described in more detail in the appendices to the Medica Participation Agreement.
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