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Copyright© 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.
UB-92 (Uniform Billing Code of 1992) - Bill form used to submit hospital insurance claims for payment by third parties. Similar to legacy HCFA 1500, but reserved for the inpatient component of health services.
An electronic format of the CMS-1450 paper claim form that has been in general use since 1993.
UCR - See Usual, Customary and Reasonable.
UM - See Utilization Management.
Unassigned Claim - A claim submitted for a service or supply by a provider who does not accept assignment. Also see Assignment of Benefits.
Unbundling - A coding inconsistency that involves separating a procedure into parts and charging for each part rather than using a single code. The practice of providers billing for a package of health care procedures on an individual basis when a single procedure could be used to describe the combined service.
Unbundling is disallowed by many MCOs.
Uncompensated Care - Service provided by physicians and hospitals for which no payment is received from the patient or from third-party payers. Some costs for these services may be covered through cost-shifting. Not all uncompensated care results from charity care. It also includes bad debts from persons who are not classified as charity cases but who are unable or unwilling to pay their bill. See cost shifting.
Underinsured - People with public or private insurance policies that do not cover all necessary health care services, resulting in out-of-pocket expenses that exceed their ability to pay. See cost shifting.
Underwriting - Process of selecting, classifying, analyzing and assuming risk according to insurability. The insurance function bearing the risk of adverse price fluctuations during a particular period. Analysis of a group that is done to determine rates or to determine whether the group should be offered coverage at all.
Underwriting Impairments - Factors that tend to increase an individual's risk above that which is normal for his or her age.
Underwriting Manual - A document that provides background information about various underwriting impairments and suggests the appropriate action to take if such impairments exist.
Underwriting Requirements - Requirements, sometimes relating to group characteristics or financing measures, that MCOs at times impose in order to provide healthcare coverage to a given group and which are designed to balance a health plan's knowledge of a proposed group with the ability of the group to voluntarily select against the plan. Also see Antiselection.
Uninsured - People who lack public or private health insurance.
Universal Access - The right and ability to receive a comprehensive, uniform, and affordable set of confidential, appropriate, and effective health services. Universal service is a reality in countries with national medicine programs or socialized healthcare, such as the UK, Canada, France and most countries in the world. Few countries have the private insurance programs as the primary form of healthcare, as in the US. See Universal Coverage.
Universal Coverage - A type of government sponsored health plan that would provide healthcare coverage to all citizens. This is an aspect of Clinton's original health plan in the mid 1990s and is an attribute of national health insurance plans similar to those offered in other countries such as the UK or Canada. While government sponsored health care is not likely to be universal, politicians in Washington continuously discuss the concept of providing healthcare to all Americans. Expect to see more and more discussion of modified universal coverage ideas in the years to come. See also National Health Insurance.
Update Factor - The year-to-year increase in base payment amounts for PPS and excluded hospitals and dialysis facilities. The update factors generally are legislated by the Congress after considering annual recommendations provided by ProPAC and HHS.
Upcoding - A coding inconsistency that involves using a code for a procedure or diagnosis that is more complex than the actual procedure or diagnosis and that results in higher reimbursement to the provider.
UR - See Utilization Review.
URO - See Utilization Review Organization.
Urgently Needed Care - A CMS term, it refers to care that an enrollee receives for a sudden illness or injury that needs medical care right away, but is not life threatening. Primary care doctor generally provides urgently needed care if the enrollee is in a Medicare health plan other than the Original Medicare Plan. If the enrollee is out of your plan's service area for a short time and cannot wait until returning home, the health plan must pay for urgently needed care.
Urgent Services - Benefits covered in an Evidence of Coverage that are required in order to prevent serious deterioration of an insured's health that results from an unforeseen illness or injury.
Use – Under HIPAA, this term refers to the sharing of individually identifiable health information within a covered entity. For Partners' purposes, a use is the sharing of such information within the Partners affiliated covered entity.
U.S. Per Capita Cost (USPCC) - The national average cost per Medicare beneficiary, calculated annually by CMS’s Office of the Actuary. See also Capitation or CMS.
Usual, Customary and Reasonable (UCR) - Referring to charges for medical services, the UCR is the amount a health plan will recognize for payment for a particular medical procedure. It is typically based on what is considered "reasonable" for that procedure in your service area. Commonly charged fees for health services in a certain area. The use of fee screens to determine the lowest value of provider reimbursement based on: (1) the provider's usual charge for a given procedure, (2) the amount customarily charged for the service by other providers in the area (often defined as a specific percentile of all charges in the community), and (3) the reasonable cost of services for a given patient after medical review of the case. Most health plans provide reimbursement for usual and customary charges, although no universal formula has been established for these rates.
Utilization - Use of services and supplies. Utilization is commonly examined in terms of patterns or rates of use of a single service or type of service such as hospital care, physician visits, and prescription drugs. Measurement of utilization of all medical services in combination is usually done in terms of dollar expenditures. Use is expressed in rates per unit of population at risk for a given period such as the number of admissions to the hospital per 1,000 persons over age 65 per year, or the number of visits to a physician per person per year for an annual physical. See also UR, UM.
Utilization Management (UM) - The process of evaluating the necessity, appropriateness and efficiency of health care services against established guidelines and criteria. Evaluation of the necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities. UM usually includes new actions or decisions based on the overall analysis of the utilization.
See also Case Management.
Utilization Management Committee - The MCO committee that reviews and updates the MCO's utilization management program, establishes utilization review protocols, reviews referral and utilization patterns, and reviews utilization decisions for medical appropriateness.
Utilization Review (UR) - A formal review of utilization for appropriateness of health care services delivered to a member on a prospective, concurrent or retrospective basis. In a hospital, this includes review of the appropriateness of admissions, services ordered and provided, length of a stay, and discharge practices, both on a concurrent and retrospective basis. A peer review group, or a public agency can do utilization review. UR is a method of tracking, reviewing and rendering opinions regarding care provided to patients. Usually UR involves the use of protocols, benchmarks or data with which to compare specific cases to an aggregate set of cases. Those cases falling outside the protocols or range of data are reviewed individually. Managed care organizations will sometimes refuse to reimburse or pay for services that do not meet their own sets of UR standards. UR involves the review of patient records and patient bills primarily but may also include telephone conversations with providers. The practices of pre-certification, re-certification, retrospective review and concurrent review all describe UR methods. UR is one of the primary tools utilized by IDS, MCO and health plans to control over-utilization, reduce costs and manage care.Utilization Risk - The risk that actual service utilization might differ from utilization projections.
See also Pre-Authorization and Case Management.
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.