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S-Z
Identification Card Issued to members by Medica, this card contains member’s name and number, and identification of member’s specific benefit document. When applicable, also indentifies member’s primary care clinic.
Improvement Plan The recommendation(s) for action that is made following analysis of study findings.
Indicator A quantitative value that reflects the condition and direction over time of a specified process or outcome.
International Classification of Diseases, 9th Ed., Clinical Modification (ICD-9-CM) A numerical coding system for classifying diseases and operations that is used to identify patient diagnoses linked to physician services by payers and insurers.
Return to top.Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
A private, not-for-profit organization that evaluates and accredits hospitals and other health care organizations providing home care, mental health care, ambulatory care and long-term care.
Return to top.Length of Stay (LOS) The number of days a member stayed in an inpatient facility.
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MSHO See Minnesota Senior Health Options.
Managed Care Organization (MCO)
A system of health care delivery that influences utilization and cost of services and also measures performance. The goal is to achieve a system that delivers value by giving members access to quality, cost-effective health care.
Medica In this manual, unless otherwise stated, all references to Medica include Medica-(MN), MIC, MHPW and MSI, defined as follows. Medica-(MN) is a health maintenance organization organized pursuant to the laws of the State of Minnesota. Medica Insurance Company (MIC) is a stock insurance company organized pursuant to the laws of the State of Minnesota. Medica Health Plans of Wisconsin (MHPW) is a health maintenance organization organized pursuant to the insurance laws of Wisconsin. Medica Self-Insured (MSI) is a Minnesota nonprofit corporation.
Medicaid A federally aided, and state-operated and administered program that provides certain health care benefits to eligible low-income people. This program is referred to as Medical Assistance (MA). Medica Choice Care is the product designed for Medicaid recipients.
Medical Policy Committee (MPC) Advises Medica on matters of medical appropriateness regarding utilization review, prior authorization utilization management policies and clinical guidelines. The MPC is composed of appointed, board-certified, practicing physicians in family practice, internal medicine, obstetrics and gynecology, and pediatrics, as well as a consumer representative.
Medical Policy Manual
A clinical reference that contains utilization management policies, clinical guidelines and medical technology policies.
Learn more about Medical Policies and Clinical Guidelines.
Medical Record The record in which clinical information related to the provision of physical, social and mental health services is documented.
Medical Trend The year-to-year increase or inflation in medical costs.
Medically Necessary Diagnostic testing, preventive services and medical treatment consistent with the diagnosis of a prescribed course of treatment for a member’s condition, which Medica determines on a case-by-case basis according to the:
- Consistency with medical standards and accepted practice parameters of the community as determined by health care providers in the same or similar general specialty and considered appropriate for the member’s condition.
- Ability to help restore or maintain a member’s health.
- Ability to prevent deterioration of a member’s condition.
- Ability to prevent the likely onset of a health problem or detect an incipient problem.
- Nonexclusion from the member’s benefit document.
The fact that a provider has performed, prescribed or recommended a service, or that a service is the only available treatment, may not mean the service is medically necessary and a covered benefit.
Medicare
A program administered by the Social Security Administration that covers the medical care of individuals over age 65 and certain qualified persons under age 65.
Medicare Approved Amount The portion of Medicare eligible expenses for health services allowed and reimbursed by Medicare.
Medicare Coinsurance The percentage charge of the Medicare eligible expenses not reimbursed by Medicare.
Medicare Contract A contract entered into between Medica and CMS that governs the arrangement Medica has with participating providers regarding the provision of health services to Medica Select Solution™ and Medica Prime Solution™ members.
Medicare Deductible The dollar charge of the Medicare eligible expenses not paid by Medicare.
Medicare Eligible Expense The customary charge for health services provided to Medica Select Solution™ and Medica Prime Solution™ members to the extent recognized by Medicare as reasonable and medically necessary. Non-Medicare eligible expenses are those health care expenses not covered by Medicare.
Medicare Part A Funds created under the Social Security Act to provide hospital insurance coverage to Medicare beneficiaries, including inpatient services and supplies.
Medicare Part B Funds created under the Social Security Act to provide supplementary medical insurance to Medicare beneficiaries for various nonhospital services, including physician’s services, outpatient hospital care and some medical supplies.
MedImpact The company Medica contracts with to coordinate pharmaceutical services to Medica members.
Member An individual properly enrolled for coverage under a benefit document. Also referred to as a “covered person” in self-insured plans. Member Identification Number The 16-digit number that identifies a patient as a Medica member. The member number consists of a member’s group number, an identification number (typically the subscriber’s social security number) and a two-digit family number.
Minnesota Department of Commerce (MDOC) The state government agency responsible for regulation and licensing of insurance companies.
Minnesota Department of Health (MDH) The state government agency responsible for regulation of health care delivery, including licensing and regulation of HMOs.
Minnesota Department of Human Services (MDHS) The state government agency responsible for administration of General Assistance Medical Care (GAMC) and Medicaid.
Minnesota Senior Health Options (MSHO)
A demonstration project by the Minnesota Department of Human Services that creates an alternative delivery system for acute and long-term care services and integrates Medicare and Medicaid funding for persons age 65 and over who are eligible for Medicare and Medicaid. Medica DUAL Solution™ is Medica’s MSHO health plan.
Modifier A two-digit suffix code that allows reporting of an altered service or procedure without changing the definition of the procedure code. Monitoring Activity The collection of information relating to quality of care. Monitoring activities may be prospective, concurrent or retrospective audits; reports; surveys; observations; interviews; complaints; peer reviews; or focused studies.
Return to top.National Committee for Quality Assurance (NCQA) A nonprofit organization that seeks to improve patient care and health plan performance in partnership with managed care plans, purchasers, consumers and the public sector. NCQA evaluates health plans’ internal quality processes through accreditation reviews and works to develop health plan performance measures.
Net Service Fee Revenue (NSFR) The MSHO capitation received by Medica less Minnesota Comprehensive Health Associate tax assessed on the Medicare Capitation, the MA surcharge and the one percent premium tax.
Nonparticipating Provider (a.k.a. Nonnetwork Provider) A health care provider who is appropriately licensed in the state or states where the provider renders health services, but has not contracted with Medica to be a participating provider.
Nursing Home Certifiable A designation indicating, based on the pre-admission screening (PAS), that a Medicare enrollee is in need of nursing facility level of care, but has decided to remain living in the community.
Return to top.Return to Glossary of Terms.