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Safety The degree to which the risk of an intervention and the risk in the care environment are reduced for the member and others, including the health care provider.
Service Area The geographic area where Medica is licensed or contracted to sell health care products.
Skilled Care Nursing or rehabilitation services requiring the skills of technical or professional medical personnel to develop, provide and evaluate care and assess a member’s changing condition.
Skilled Nursing Facility (SNF) A licensed bed or facility (including an extended care facility, hospital swing bed and transitional care unit) that provides skilled transitional care.
Skilled Nursing Facility (SNF) Review
A medical record review for quality concerns in skilled nursing facilities.
Standards Professionally developed expressions of the range of acceptable variation from a norm or criterion.
Standing Referral A referral used by a network provider and authorized by Medica for conditions that require ongoing services from a non-network specialist provider. A standing referral will only be authorized for the period of time appropriate to the member’s medical condition.
Study A generic term used to refer to a quality improvement audit or a monitoring activity.
Sub-capitation Where the care system capitates a contracted clinic entity.
Suspending Participation or Suspension Making a provider ineligible for reimbursement by Medica for a stated period of time.
Suspending Payments Stopping any or all payments for health services billed by a provider pending resolution of the matter in dispute between the provider and Medica.
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Third-party Administrator (TPA) An independent, corporate entity responsible for administration of an employer’s group benefit plan(s), claim reimbursement and self-insured programs. A TPA does not underwrite or assume group risk.
Third-party Payer
“A person, entity, agency, or government program…that has a probable obligation to pay all or part of the costs of a recipient’s health services. Examples are an insurance company, health maintenance organization, the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), workers’ compensation, and defendants illegal actions arising out of an accidental or intentional tort” (Minnesota Rules, part 9505.0015, subpart 46).
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Uniform Billing Code of 1992 (UB-92) A federal directive requiring a hospital to follow specific billing procedures that itemize all services included and billed on each claim.
United Behavioral Health (UBH) The mental health and substance abuse services (MH/SA) division of United HealthCare Corporation (UHC) with which Medica has contracted to provide MH/SA services to Medica members.
United HealthCare Corporation (UHC) The company with which Medica has contracted to provide administrative services.
Urgent Care Center A health care facility–distinguishable from an affiliated clinic or hospital–the primary purpose of which is to offer and provide immediate, short-term medical care for minor, immediate medical conditions on a regular or routine basis.
Utilization Review A process of evaluating use and consumption of health care services, along with level and intensity of care, for appropriateness and efficiency.
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WebMD Office® An internet site designed specifically for health care providers that offers secure encrypted transactions, including eligibility, provider number search, secure mail, referrals and claim status with adjustments.
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