To search this site, click here.
"I will not join any club that will not have me as a member." (Groucho Marx)
Copyright© 1997 - 2011, Pam Pohly, All Rights Reserved.
This glossary can also be purchased in printed book format.
Glossary of Terms in Managed Health Care
The following are definitions of commonly used terms in the medical provider, hospital and managed care industries. This dictionary is comprised of 26 individual pages, one for each letter of the alphabet. To find a certain word that starts with this letter of the alphabet, may we suggest that you please try the "find" or "search" function in your browser. Or you may simply scroll down the list. If your word starts with another letter, please use the alphabet index below.
This glossary can also be purchased in printed book format if you would like to keep it handy in your desk or briefcase.
EAP - See Employee Assistance Program
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) - A Medicaid program for recipients younger than 21 that provides screening, vision, hearing, and dental services at intervals that meet recognized standards of medical and dental practices and at other intervals as necessary to determine the existence of physical or mental illnesses or conditions.
ECF - See Extended Care Facility.
Economic Credentialing - The use of economic criteria unrelated to quality of care or professional competency in determining an individual's qualifications for initial or continuing hospital medical staff membership or privileges. Economic credentialing has become a controversial topic involving much concern about ethics; yet, economic credentialing remains the most powerful form of controlling the behavior of doctors. Other forms of control include utilization review, certification, exclusive provider panels and more.
EDI Translator - Used in electronic claims and medical record transmissions, this is a software tool for accepting an EDI transmission and converting the data into another format, or for converting a non-EDI data file into an EDI format for transmission. See also Electronic Data Interchange.
Edits - Criteria that, if unmet, will cause an automated claims processing system to "kick out" a claim for further investigation.
Effective Date - The date on which a policy's coverage of a risk goes into effect.
Election - An enrollee's decision to join or leave a health plan.
Electronic Claim - A digital representation of a medical bill generated by a provider or by the provider's billing agent for submission using telecommunications to a health insurance payer. Most claims are electronically submitted.
Electronic Data Interchange (EDI) - The automated exchange of data and documents in a standardized format. In health care, some common uses of this technology include claims submission and payment, eligibility, and referral authorization.
Refers to the exchange of routine business transactions from one computer to another in a standard format, using standard communications protocols.
Electronic Media Claims - A flat file format used to transmit or transport claims, such as the 192-byte UB-92 Institutional EMC format and the 320-byte Professional EMC NSF.
Electronic Medical Record (EMR) - A computer-based record containing health care information. This technology, when fully developed, meets provider needs for real-time data access and evaluation in medical care. Together with clinical workstations and clinical data repository technologies, the EMR provides the mechanism for longitudinal data storage and access. A motivation for healthcare entities to implement this technology derives from the need for medical outcome studies, more efficient care, speedier communication among providers and management of health plans. This record may contain some, but not necessarily all, of the information that is in an individual's paper-based medical record. One goal of HIPAA is to protect identifiable health information as the system moves from a paper-based to an electronic medical record system. See also Computerized Medical Record.
Electronic Remittance Advice - Any of several electronic formats for explaining the payments of health care claims.
Eligible Dependent - Person entitled to receive health benefits from someone else's plan. See also Dependent.
Eligible Employee - Employee who qualifies to receive benefits.
Eligible Expenses - Charges covered under a health plan. See also Covered Services, Approved Services.
Eligible Person - Person who meets the qualifications of a health plan contract.
Elimination Period - Most often used to designate the waiting period in a health insurance policy.
Emergency - Sudden unexpected onset of illness or injury which requires the immediate care and attention of a qualified physician, and which, if not treated immediately, would jeopardize or impair the health of the Member, as determined by the payer's Medical Staff. Significant in that Emergency may be the only acceptable reason for admission without pre-certification.
Emergency Center, Emergi-center - Non-hospital affiliated health facility that provides short-term care for minor medical emergencies or procedures needing immediate treatment; also called urgi-center, urgent center or free standing emergency medical service center.
Emergency Medical Treatment and Labor Act (EMTALA) - An act pertaining to emergency medical situations. EMTALA requires hospitals to provide emergency treatment to individuals, regardless of insurance status and ability to pay.
Employee Assistance Program (EAP) - A service, plan or set of benefits that are designed for personal or family problems, including mental health, substance abuse, gambling addiction, marital problems, parenting problems, emotional problems or financial pressures. This is usually a service provided by an employer to the employees, designed to assist employees in getting help for these problems so that they may remain on the job. EAP began with a primary drug and alcohol focus with an emphasis on rehabilitating valued employees rather than terminating them for their substance problems. It is sometimes implemented with a disciplinary program that requires that the impaired employee participate in EAP in order to retain employment. With the advent of managed care, EAP has sometimes evolved to include case management, utilization review and gatekeeping functions for the psychiatric and substance abuse health benefits.
Employee Retirement Income Security Act of 1974 (ERISA) - Also called the Pension Reform Act, this act regulates the majority of private pension and welfare group benefit plans in the U.S. It sets forth requirements governing, among many areas, participation, crediting of service, vesting, communication and disclosure, funding, and fiduciary conduct. Key legislative battleground now, because ERISA exempts most large self-funded plans from State regulation and, hence, from any reform activities undertaken at state level, which is now the arena for continued healthcare reform.
Employer Mandate - Under the Federal HMO Act, describes conditions when federally qualified HMOs can mandate or require an employer to offer at least one federally qualified HMO plan of each type (IPA/network or group/staff). Option that federally qualified HMOs have to exercise over employees, requiring them to have available one or more types of HMOs per plan. This requirement was sunsetted in 1995.
Employer Purchasing Coalitions - See Purchasing Alliances.
Employment Model IDS - An integrated delivery system that generally owns or is affiliated with a hospital and establishes or purchases physician practices and retains the physicians as employees.
EMR - See Electronic Medical Record
EMTALA - See Emergency Medical Treatment and Labor Act.
Encounter - A contact between an individual and the health care system for a health care service or set of services related to one or more medical conditions.
Encounter Data - Data relating to treatment or service rendered by a provider to a patient, regardless of whether the provider was reimbursed on a capitated or fee-for-service basis. Used in determining the level of service.
Encounter Report - A report that supplies management information about services provided each time a patient visits a provider.
Enrolled Group - Persons with the same employer or with membership in an organization in common, who are enrolled collectively in a health plan. Often, there are stipulations regarding the minimum size of the group and the minimum percentage of the group that must enroll before the coverage is available. Same as Contract group.
Enrollee - Any person eligible as either a subscriber or a dependent for service in accordance with a contract. The same as beneficiary, individual, or member of a health plan.
Enrollment - Initial process whereby new individuals apply and are accepted as members of a prepayment plan. The total number of covered persons in a health plan. Also refers to the process by which a health plan enrolls groups and individuals for membership or the number of enrollees who sign up in any one group.
Enrollment and Payment System (EPS) - A term used to cover all of the health plan or partner company activities involved in developing and administering its various aspects such as enrollment, payments, appeals, etc.
EOC or EOB - See Evidence or Explanation of Coverage or Explanation of Benefits
EPA - See Exclusive Provider Arrangement.
Episode of Care - A term used to describe and measure the various health care services and encounters rendered in connection with identified injury or period of illness.
EPO - See Exclusive Provider Organization.
EPS - See Enrollment and Payment System.
EPSDT - See Early and Periodic Screening, Diagnosis, and Treatment.
EQRO - See External Quality Review Organization.
ERISA - See Employee Retirement Income Security Act.
Essential Community Providers - Providers such as community health centers that have traditionally served low-income populations.
Ethics in Patient Referrals Act - A federal act which, along with its amendments, prohibits a physician from referring patients to laboratories, radiology services, diagnostic services, physical therapy services, home health services, pharmacies, occupational therapy services, and suppliers of durable medical equipment in which the physician has a financial interest. Also known as the Stark Laws.
Evidence-based Medicine - Evidence-based health care is the conscientious use of current best evidence in making decisions about the care of individual patients or the delivery of health services. Term used in quality improvement and peer review programs in hospitals and health plans.
Evidence or Explanation of Coverage (EOC) - A booklet provided by the carrier to the insured summarizing benefits under an insurance plan.
Same as Explanation of Benefits.
Evidence of Insurability (E of I) - Proof of a person's physical condition that effects acceptability for insurance or a health care contract.
Exceptions Process (under a Prescription Drug Benefit Plan) - A course of action that allows patients to challenge the placement of a drug on a higher-cost tier or the exclusion of a particular drug from their formulary. Under the Prescription Drug Benefit, an exceptions process must be incorporated into both stand-alone prescription drug plans (PDP) and those that are part of a Medicare Advantage plan (MA-PD). Enrollees are able to request that a formulary drug be provided at a lower tier for cost-sharing (thereby reducing the patient’s co-pay) or that a non-formulary drug be provided by the plan. Because exceptions requests are coverage determinations, the plan must act within the time frame for standard coverage determinations (within 72 hours) or expedited coverage determinations (within 24 hours). See also Prescription Drug Benefit.
Excess Charges - Used by CMS to describe in the Medicare Plan the difference between a health care provider's actual charge (which may be limited by Medicare or the state) and the Medicare-approved payment amount.
Excess Risk - Either specific or aggregate stop loss coverage.
Excluded Hospitals and Distinct-Part Units - Hospitals and hospital units that are specifically excluded from Medicare's prospective pay system. These commonly include children's, cancer, hospital based outpatient care, long-term care, rehabilitation inpatient and psychiatric hospitals or units. Rehabilitation or psychiatric units of acute care hospitals are exempt if they meet certain criteria specified by HHS and are referred to as "DRG exempted". Excluded facilities are paid through submission of cost reports and TEFRA limits.
Exclusions - Conditions or situations not considered covered under contract or plan. Clauses in an insurance contract that deny coverage for select individuals, groups, locations, properties or risks. Providers will negotiate for exclusions for outliers and carve-out of certain high cost procedures, while payers will negotiate for exclusions to avoid payment of higher cost care.
Exclusive Provider Arrangement (EPA) - An indemnity or service plan that provides benefits only if care is rendered by the institutional and professional providers with which it contracts (with some exceptions for emergency and out-of-area services).
Exclusive Provider Organization (EPO) - A plan that limits coverage of non-emergency care to contracted health care providers. Operates similar to an HMO plan but is usually offered as an insured or self-funded product. Sometimes looks like a managed care organization that is organized similarly to a PPO in that physicians do not receive capitated payments, but the plan only allows patients to choose medical care from network providers. If a patient elects to seek care outside of the network, then he or she will usually not be reimbursed for the cost of the treatment. Uses a small network of providers and has primary care physicians serving as care coordinators (or gatekeepers). Typically, an EPO has financial incentives for physicians to practice cost-effective medicine by using either a prepaid per-capita rate or a discounted fee schedule, plus a bonus if cost targets are met. Most EPOs are forms of POS plans because they pay for some out-of-network care.
Exclusivity Clause - A part of a contract which prohibits physicians, providers or other care entities from contracting with more than one managed care organization. Exclusive contracts are common in staff model HMOs and IPAs but becoming less common in other health plan contracting.
Expansion - Some HMOs compute Plan expansion as part of the capitation rate in order to provide the necessary capital for growth.
Expedited Organization Determination - A fast decision from a Medicare+Choice organization about whether it will provide a health service. A beneficiary may receive a fast decision within 72 hours when life, health or ability to regain function may be jeopardized.
Experience - A term used to describe the relationship of premium to claims for a plan, coverage, or benefits for a stated time period. Usually expressed as a ratio or percent. See also Medical Loss Ratio.
Experience Rating - The process of setting rates partially or in whole on evaluating previous claims experience for a specific group or pool of groups. The rating system by which the Plan determines the capitation rate or premium rate is determined by the experience of the individual group enrolled, based on actual or anticipated health care use by the specific group of insureds. Each group will have a different rate based on utilization. This system tends to penalize small groups with high utilization. A method of adjusting health plan premiums based on the historical utilization data and distinguishing characteristics of a specific subscriber group, such as determining the premium based on a group's claims experience, age, sex or health status. Experience rating is not allowed for federally qualified HMOs.
Experience-Rated Premium - A premium with is based upon the anticipated claims experience of, or utilization of service by, a contract group according to its age, sex, constitution, and any other attributes expected to affect its health service utilization, and which is subject to periodic adjustment in line with actual claims or utilization experience.
Explanation of Benefits (EOB) - A statement sent to covered individuals explaining services provided, amount to be billed, and payments made. A summary of benefits provided subscribers by the carrier.
Same as Evidence of Coverage.
Extended Care Facility (ECF) - A nursing, long-term, or convalescent home offering skilled nursing care and rehabilitation services on a 24-hour basis.
Extension of Benefits - Insurance policy provision that allows medical coverage to continue past termination of employments. See also COBRA.External Quality Review Organization (EQRO) - States are required to contract with an entity that is external to and independent of the State and its HMO and HIO contractors to perform an annual review of the quality of services furnished by each HMO or HIO contractor.
This glossary can also be purchased in printed book format if you would like to have a copy for your briefcase or desk.
Copyright© 1997 - Present Date, Pam Pohly, All Rights Reserved.