To search this site, click here.
"Success is having ten honeydew melons and eating only the top half of each one." (Barbara Streisand)
Copyrightę 1997 - 2011, Pam Pohly, All Rights Reserved.
This glossary can now 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 have it handy at your desk.
National Accounts - Large group accounts that have employees in more than one geographic area that are covered through a single national contract for health coverage. Contrast with large local groups.
National Claims History System (NCH) - A CMS data reporting system that combines both Part A and Part B claims in a common file. The NCH system became fully operational in 1991.
National Committee for Quality Assurance (NCQA) - A non-profit organization created to improve patient care quality and health plan performance in partnership with managed care plans, purchasers, consumers, and the public sector.
NCQA was formed in 1979 by the managed care industry and became independent in 1990. NCQA review is voluntary for health plans, but most plans seek its accreditation. The object of NCQA review and accreditation is to provide information to purchasers and patients and to encourage plans to compete based on quality and value rather than solely on price and provider network.
National Council for Prescription Drug Programs - An ANSI-accredited group that maintains a number of standard formats for use by the retail pharmacy industry, some of which have been adopted as HIPAA standards.
National Drug Code (NDC) - A medical code set maintained by the Food and Drug Administration that contains codes for drugs that are FDA-approved. The Secretary of HHS adopted this code set as the standard for reporting drugs and biologics on standard transactions. Classification system for drug identification, similar to UPC code.
National Health Insurance - Proposal by politicians to make government the single payer for all health care, similar to Great Britain or Canada. Providers like some aspects of this idea because it provides for "universal coverage" for all citizens. However, businesses and providers (as businesses themselves) dislike the idea of the government administering a program that they will either have to fund or be funded by. Proposals for national health insurance are surely to be debated by politicians for many years to come. See also Universal Coverage.
National Practitioner Data Bank (NPDB) - A computerized data bank maintained by the federal government that contains information on physicians against whom malpractice claims have been paid or certain disciplinary actions have been taken. Hospitals and other agencies pay a fee to access these records. Many regulatory agencies now require hospitals to utilize the NPDB prior to credentialing physicians at their facilities.
National Provider Identifier - A system for uniquely identifying all providers of health care services, supplies, and equipment. A term proposed by the Secretary of HHS as the standard identifier for health care providers.
NCH - See National Claims History System.
NCQA - See National Committee for Quality Assurance.
NDC - See National Drug Code.
Neonatal Intensive Care Unit (NICU) - A hospital unit with special equipment for the care of premature and seriously ill newborn infants.
Network - An affiliation of providers through formal and informal contracts and agreements. Networks may contract externally to obtain administrative and financial services. A list of physicians, hospitals and other providers who provide health care services to the beneficiaries of a specific managed care organization. See also IDS, PPO, PHO or Hospital Alliances.
Network Model HMO - This type of HMO contracts with more than one physician group and may contract with single or multi-specialty groups as well as hospitals and other health care providers. A health plan that contracts with multiple physician groups to deliver health care to members. Generally limited to large single or multi-specialty groups. Distinguished from group model plans that contract with a single medical group, IPA's that contract through an intermediary, and direct contract model plans that contract with individual physicians in the community.
Newborns' and Mothers' Health Protection Act (NMHPA) - A law which specifies that group health plans or group healthcare insurers cannot mandate that hospital stays following childbirth be shorter than 48 hours for normal deliveries or 96 hours for cesarean births.
New Business Underwriting - The risk evaluation an MCO performs when it first issues coverage to a group.
NMHPA - See Newborns' and Mothers' Health Protection Act.
No Balance Billing Provision - A provider contract clause which states that the provider agrees to accept the amount the plan pays for medical services as payment in full and not to bill plan members for additional amounts (except for copayments, coinsurance, and deductibles).
Non-Formulary Drugs - Drugs not on a plan-approved drug list. See also Formulary.
Non-Group Market - A market segment that consists of customers who are covered under an individual contract for health coverage or enrolled in a government program.
Non-Maleficence - An ethical principle which, when applied to managed care, states that managed care organizations and their providers are obligated not to harm their members.
Non-Participating Physician (or Provider) - A provider, doctor or hospital that does not sign a contract to participate in a health plan, usually which requires reduced rates from the provider. In the Medicare Program, this refers to providers who are therefore not obligated to accept assignment on all Medicare claims. In commercial plans, non-participating providers are also called out of network providers or out of plan providers. If a beneficiary receives service from an out of network provider, the health plan (other than Medicare) will pay for the service at a reduced rate or will not pay at all.
Non-Plan Provider - A health care provider without a contract with an insurer. Same as Non-Participating Provider.
Nosocomial Infections - Infections that are acquired while a patient is in a hospital are referred to as nosocomial infections; a term derived from 'nosos' the Greek word for 'disease'. Often nosocomial infections become apparent while the patient is still in the hospital but in some cases symptoms may not show up until after the affected patient is discharged. About one patient in ten acquires an infection as a direct result of being hospitalized. Infection control can be very cost-effective. Approximately one third of nosocomial infections are preventable.
Also called Hospital-Based Infections. Some states are now requiring that hospitals keep transparent records and publicly report their nosocomial rates of infection, however, most states allow hospitals to keep this information private.See Hospital-Acquired Infection.
NPDB - See National Practitioner Data Bank.
NPLANID - A term used by CMS for a proposed standard identifier for health plans. CMS had previously used the terms PayerID and PlanID for the health plan identifier.Nurse Practitioner (NP) - A registered nurse qualified and specially trained to provide primary care, including primary health care in homes and in ambulatory care facilities, long-term care facilities, and other health care institutions. Normally, NPs are licensed and possess masters degrees. Nurse practitioners generally function under the supervision of a physician but not necessarily in his/her or her presence. In some states, NPs are able to provide basic medical services without requiring MD or DO supervision. They are either salaried or reimbursed on a fee-for-service basis. See also Midlevel Practitioners.
This glossary can also be purchased in printed book format if you would like to have a copy for your briefcase or desk.
Copyrightę 1997 - Present Date, Pam Pohly, All Rights Reserved.