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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 now also be purchased in printed book format if you would like to have it always accessible to you.
Large Claim Pooling - System that isolates claims above a certain level and charges them to a pool funded by charges of all groups who share the pool. Designed to help stabilize significant premium fluctuations.
Large Group - A large pool of individuals for which health coverage is provided by the group sponsor. A large group may be defined as more than 250, 500, 1,000, or some other number of members, depending on the MCO.
Large Local Groups - Accounts that contract on a local basis for group employee health benefits. Contrast with national accounts.
Large Urban Area - An urban statistical region with population of one million or more.
Legacy Systems - Computer applications, both hardware and software, which have been inherited through previous acquisition and installation. Most often, these systems run business applications that are not integrated with each other. Newer systems which stress open design and distributed processing capacity are gradually replacing such systems.
This term is used frequently in discussing HIPAA and its computing requirements. See also HIPAA.
Legend Drug - Drug that the law says can only be obtained by prescription.
Length of Stay (LOS) - The duration of an episode of care for a covered person. The number of days an individual stays in a hospital or inpatient facility. May also be reviewed as Average Length of Stay (ALOS).
Licensing - A process most States employ, which involves the review and approval of applications from HMOs prior to beginning operation in certain areas of the State. Areas examined by the licensing authority include: fiscal soundness, network capacity, MIS, and quality assurance. The applicant must demonstrate it can meet all existing statutory and regulatory requirements prior to beginning operations.
Lifetime Limit - A cap on the benefits paid under a policy. For example, many policies have a lifetime limit of $1 million, which means that the insurer agrees to cover up to $1 million in covered services over the life of the policy.
Lifetime Reserve Days - In the Original Medicare Plan, a total of 60 extra days that Medicare will pay for when an enrollee is in a hospital more than 90 days during a benefit period. Once these 60 reserve days are used, the citizen does not get any more extra days during his or her lifetime. For each lifetime reserve day, Medicare pays all covered costs except for a daily coinsurance.
Limited Data Set – Under HIPAA, this term refers to a set of data that may be used for research, public health or health care operations without an authorization or waiver of authorization. The limited data set is defined as PHI that excludes the following direct identifiers of the individual or of relatives, employers or household members of the individual: names; postal address information, (other than town or city, State and zip code); telephone and FAX numbers; electronic mail addresses; SSN; medical record numbers; health plan beneficiary numbers; account numbers; certificate/license numbers; vehicle identifiers and serial numbers, including license plates; device identifiers and serial numbers; web universal resource locators (URLs); internet protocol (IP) address; biometric identifiers, including finger and voice prints; full face photos, and comparable images. A covered entity must enter into a data use agreement with the recipient of a limited data set. It should be noted that although a limited data set is subject to only select provisions of the HIPAA Privacy Rule, it may be covered by the Common Rule.
Limiting Charge - The maximum amount that a non-participating physician is permitted to charge a Medicare beneficiary for a particularly defined procedure or bundled service. These limits are published by the individual state intermediaries for Medicare and CMS and are usually combined in reports with the allowed charges and regional payment schedules. In 1993, the limiting charge was set at 115 percent of the Medicare-allowed charge. The limiting charge is 15% over Medicare’s approved amount. The limiting charge only applies to certain services and doesn’t apply to supplies or equipment and may not reflect what the physician will be paid.
Local Access Transport Area (LATA) - A defined region in which a telephone and long distance carrier operates. Important concept for those CHINs that depend upon phone lines. When creating communications networks, you try to avoid crossing boundaries of these, if possible, since costs escalate dramatically when there is a need to communicate over more than one LATA. See also CHIN.
Local Codes - A generic term for code values that are defined for a State or other local division or for a specific payer. Commonly used to describe HCPCS Level III Codes.
Local Exchange Carrier (LEC) - The telephone company that provides and supports the local connection to the public switched telephone network. In many areas of the US, the LEC is one of the seven regional Bell operating companies (RBOCs) or "Baby Bells," although these companies are undergoing dramatic mergers now. These LECs become partners for organizations seeking to develop a CHIN or, more conservatively, simply seeking to integrate their information system across many sites within a region.
See also CHIN.
Lock-in - A contractual provision by which members are required to use certain health care providers in order to receive coverage (except in cases of urgent or emergent need).
Long-term Care (LTC) - A set of health care, personal care and social services required by persons who have lost, or never acquired, some degree of functional capacity (e.g., the chronically ill, aged, disabled, or retarded) in an institution or at home, on a long-term basis. The term is often used more narrowly to refer only to long-term institutional care such as that provided in nursing homes, homes for the retarded and mental hospitals. Long-term care can be provided at home, in the community, or in various types of facilities, including nursing homes and assisted living facilities. Most long-term care is custodial care. Medicare doesn’t pay for this type of care if this is the only kind of care a person needs. However, Medicaid and long-term care insurance plans do provide some coverage for long-term care. Ambulatory services such home health care, which can also be provided on a long-term basis, are seen as alternatives to long-term institutional care.
Long-term Care Insurance - Insurance designed to pay for some or all of the costs of long term care.
LOS - See Length of Stay.
Loss Rate - The number and timing of losses that will occur in a given group of insureds while the coverage is in force.Loss Ratio - Incurred claims plus expenses, divided by paid premiums. See also Incurred Claims Loss Ratio.
LTC - See Long-term Care.
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.