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Find out more about CACIHealth
A Glossary of Managed Care and Healthcare Terms
Select a letter to go to that part of the alphabet.
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
A
(AAHC) American Accreditation Healthcare Commission - a partnership with representation from the managed healthcare industry,
healthcare providers, the public and regulators. AAHC establishes utilization review industry standards that encourage efficient medical review
processes for all affected parties and provide a method for the evaluation and accreditation of utilization review programs. AAHC was formerly known as
the Utilization Review Accreditation Commission (URAC). Return to Acronyms page
(ACR) Adjusted Community Rating - the community rating modified by group specific demographics combined with local experience.
Return to Acronyms page
(ACRP) Adjusted Community Rate Proposal - an estimate of a Medicare risk plan's per capita revenue requirements to provide
covered services for an individual in a county; based on the factors of age, gender, institutional status, disability, employment status and end-stage
renal disease. HCFA requires all Medicare HMOs to submit an adjusted community rate proposal
annually. Return to Acronyms page
(ADS) Alternative Delivery Systems - historically, this term refers to all forms of healthcare delivery, except traditional
fee for service. ADS includes HMOs, PPOs, IPAs and other systems for
providing healthcare. Return to Acronyms page
(ALOS) Average Length of Stay - the average number of days in an inpatient facility for each admission. The formula is number
of inpatient days/number of admissions. Return to Acronyms page
(APT) Admissions/1000 - the number of hospital admissions per 1000 health plan members. The formula for this measure is
(number of admissions/member months) X members/1000 X number of months. Return to Acronyms page
(ASO) Administrative Services Only - the management services provided by a third party for an employer group that is at risk
for the cost of healthcare services. Management services may include claim payments, medical management services and/or network access - a common
arrangement when an employer sponsors a self-funded health benefit program. Return to Acronyms page
(ASR) Age/Gender Rates - defined rates for a group product with a separate rate for each grouping of age/gender categories.
One overall table serves a defined group or product and the rates are used to calculate premiums for group billing purposes. This type of premium
structure is often preferred over single and family rating for small groups because it automatically adjusts to demographic changes in the group. Also
called table rates. Return to Acronyms page
(AWP) Average Wholesale Price - the price of a prescription medication calculated by averaging the prices of an undiscounted
pharmaceutical charged by a large group of pharmaceutical wholesale suppliers to a pharmacy provider.
Return to Acronyms page
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B
Business Rule - from the business perspective guidance that there is an obligation, directive or requirement concerning conduct, action, practice
or procedure within a particular activity or sphere. From the information system perspective a statement that defines or constrains some aspect of the
business. It is intended to assert business structure or to control or influence the behavior and processes of a business.
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C
(Cap) Capitation - a fixed fee established to cover the costs of healthcare delivered to a person. The term often refers to a
negotiated per capita rate to be prepaid, usually monthly, to a healthcare provider. It often includes a mechanism that sets an upper limit on the risk
assumed by the provider. The provider is responsible for delivering, or arranging for the delivery of, all health services required by the covered
person under the conditions of the carrier-provider contract. Return to Acronyms page
(CMP) Competitive Medical Plan - the status granted by the federal government to an organization meeting specified criteria
that enables that organization to obtain a Medicare risk contract. (No longer applicable under the Balanced Budget Act of 1997.) Can also mean certified
medical planner. Return to Acronyms page
(COA) Certificate Of Authority - a certificate issued by a state government licensing the operation of a
health maintenance organization. Return to Acronyms page
(COB) Coordination Of Benefits - a provision in a contract that applies when a person is covered under more than one group
medical program. It requires that payments of benefits will be coordinated by all programs to eliminate over insurance or duplication of payments.
Return to Acronyms page
(COBRA) Consolidated Omnibus Budget Reconciliation Act - a federal law that requires employers to offer continued health
insurance coverage to certain employees and their beneficiaries whose group health insurance coverage has been terminated. Applies to employers with 20
or more eligible employees. Typically, it makes continued coverage available for up to 18 months. COBRA enrollees are required to pay 100% of the premium
plus an additional 2% service fee. Return to Acronyms page
(COC) Certificate Of Coverage - a description of the benefits included in a carrier's plan. The certificate of coverage is
required by state laws and represents the coverage provided under the contract issued to the employer. The certificate is provided to the employee and
also is known as their member certificate. Return to Acronyms page
(CON) Certificate Of Need - a certificate issued by a government body to an individual or organization proposing to construct
or modify a health facility, acquire major new medical equipment or offer a new or different health service. Issuance recognizes that a facility or
service, when available, will meet the needs of those for whom it is intended. Return to Acronyms page
(CPT) Physician's Current Procedural Terminology - a list of medical services and procedures performed by physicians and other
healthcare providers. Each service and/or procedure is identified by its own unique five-digit code. CPT has become the healthcare industry's standard
for reporting of physician procedures and services. Return to Acronyms page
(CR) Carrier Replacement - a situation where a sole carrier replaces one or more other carriers for a specific employer group,
allowing consolidation of the group's experience and risk. Return to Acronyms page
(CRC) Community Rating By Class - the practice of community rating affected by a group's specific demographics. Also known as
factored rating. Return to Acronyms page
D
(DC) Dual Choice - a term used to describe a situation in which only two carriers are contracted by a specific group. For
example, an employer offers its employees one HMO and one indemnity plan, or two HMOs and no indemnity plan.
Return to Acronyms page
(DCA) Deferred Compensation Administrator - a company that provides services through retirement planning administration,
third-party administration, self-insured plans, compensation planning, salary survey administration and workers' compensation claims administration.
Return to Acronyms page
(DCI) Duplicate Coverage Inquiry - a request by an insurance company or group medical plan to another insurance company or
medical plan to determine if other coverage exists for the purpose of coordination of benefits.
Return to Acronyms page
(DME) Durable Medical Equipment - medical equipment which can withstand repeated use, is not disposable, is used to serve a
medical purpose, is generally not useful to a person in the absence of a sickness or injury and is appropriate for use in the home. Examples include
hospital beds, wheelchairs and oxygen equipment. Return to Acronyms page
(DOS) Date Of Service - the date healthcare services were first provided to the covered person.
Return to Acronyms page
(DPR) Drug Price Review - the weekly update of drug prices, at average wholesale price (AWP), from the American Druggist Blue
Book. Price maximums are subsequently established by the plan. Return to Acronyms page
(DPT) Days per 1000 - the number of inpatient days per 1000 health plan members. The formula is (number of days/member
months) X members/1000 X number of months. Return to Acronyms page
(DRGs) Diagnosis Related Groups - a system of classification for inpatient hospital services based on principal diagnosis,
secondary diagnosis, surgical procedures, age, gender and presence of complications. This system of classification is used as a financing mechanism to
reimburse hospital and other selected providers for services rendered, typically based on the average cost of all patients within the DRG.
Return to Acronyms page
(DSMIV) Diagnostic and Statistical Manual, Fourth Edition - American Psychiatric Association's manual of diagnostic criteria and
terminology, widely accepted as the common resource of mental health clinicians and researchers.
Return to Acronyms page
(DUE) Drug Use Evaluation - a qualitative evaluation of prescription drug use, physician prescribing patterns or patient drug
utilization to determine the appropriateness of drug therapy. Return to Acronyms page
(DUR) Drug Utilization Review - a quantitative evaluation of prescription drug use, physician prescribing patterns or patient
drug utilization to determine the appropriateness of drug therapy. Return to Acronyms page
E
(EAP) Employee Assistance Program - services designed to assist employees, their family members and employers in finding
solutions to workplace and personal problems. The EAP addresses issues that affect employee morale or an employer's productivity or financial success.
Services may include
- Assistance for family/marital concerns
- Legal or financial problems
- Elder care
- Child care
- Substance abuse
- Emotional/stress issues
- Other daily living concerns.
EAPs may address violence in the workplace, sexual harassment, dealing with troubled employees, transition in the
workplace and other events that increase the rate of absenteeism or employee turnover or reduce productivity. EAPs also can provide the voluntary or
mandatory access to behavioral health benefits through an integrated behavioral health program.
Return to Acronyms page
(EDI) Electronic Data Interchange - the computer-to-computer exchange of business or other information between two
organizations or trading partners. The data must be in either a standardized or proprietary format.
Return to Acronyms page
(EOB) Explanation Of Benefits - the coverage statement sent to covered persons listing services rendered, amounts billed and
payments made. Return to Acronyms page
(EOI) Evidence Of Insurability - proof presented through medical examination and/or through written statements about an
individual's health. Such information may be used to determine if the person will be subject to any exclusions for a pre-existing medical condition. It
also is often used to determine the rates for coverage and is usually required for those who apply for excess amounts of group life insurance. Also
known as evidence of good health. Return to Acronyms page
(EPO) Exclusive Provider Organization - provides coverage for services only from network providers.
Return to Acronyms page
(ERISA) Employee Retirement Income Security Act of 1974, Public Law 93-406 - this law mandates reporting, disclosure of
grievance and appeals requirements and fiduciary standards for group life and health plans. Sponsored by private, but not public employers. Also
preempts state benefit mandates and premium tax laws for self-funded group health plans. Return to Acronyms page
F
(FAS 106) Financial Accounting Standard 106 - a requirement that employers account for the future expected costs of retiree
health coverage as a current liability. Return to Acronyms page
(FSA) Flexible Spending Account - a mechanism by which an employee may pay for eligible dependent care or uninsured healthcare
expenses using pre-tax dollars. Through pre-tax payroll deductions a portion of the employee's salary is set aside and held by the employer for future
reimbursement to the employee. Return to Acronyms page
H
(HCFA) Health Care Financing Administration - the federal agency responsible for administering Medicare and overseeing the
states' administration of Medicaid. Return to Acronyms page
HCFA 1500 - a universal form developed by the Health Care Financing Administration (HCFA) for providers of services to
bill professional fees to health carriers. Return to Acronyms page
(HCPCS) HCFA Common Procedural Coding System - listing of services, procedures and supplies offered by physicians and other
providers. HCPCS includes CPT (Current Procedural Terminology) codes, national alphanumeric codes and local alphanumeric codes. The
national codes are developed by HCFA in order to supplement CPT codes. They include physician services not included in CPT, as well
as non-physician services such as ambulance, physical therapy and durable medical equipment. The local codes are developed by local Medicare carriers to
supplement the national codes. HCPCS codes are five-digit codes, the first digit is a letter that is followed by four numbers. HCPCS codes beginning
with A through V are national; those beginning with W through Z are local. Return to Acronyms page
(HCPP) Health Care Prepayment Plan - a cost contract with the Health Care Financing Administration that
prepays a health plan a flat monthly fee to provide Medicare-eligible Part B medical services to enrolled members. Members pay premiums to cover the
Medicare coinsurance, deductibles and co-payments, plus any additional non-Medicare covered services that the plan provides. The HCPP does not arrange
for Medicare Part A services. Eliminated by the Balanced Budget Act effective Dec. 31, 1998, except for plans sponsored by a union or employer.
Return to Acronyms page
(HEDIS) Health Plan Employer Data and Information Set - a core set of performance measures managed by the National Committee
for Quality Assurance (NCQA) to assist employers and other purchasers in evaluating health plan performance. Also used by the Health
Care Financing Administration (HCFA) to monitor quality of care given by managed care organizations.
Return to Acronyms page
(HHA) Home Health Agency - a facility or program licensed, certified or otherwise authorized according to state and federal
laws to provide healthcare services in the home. Return to Acronyms page
(HIPAA) Health Insurance Portability and Accountability Act - a federal law intended to improve the availability and
continuity of health insurance coverage that, among other things:
- Places limits on exclusions for pre-existing medical conditions
- Permits certain individuals to enroll for available group healthcare coverage when they lose other health coverage or have a new dependent
- Prohibits discrimination in group enrollment based on health status
- Guarantees the availability of health coverage to small employers and the renewability of health insurance coverage in the small and large group markets
- Requires availability of non-group coverage for certain individuals whose group coverage is terminated
(HIPC) Health Insurance Purchasing Cooperatives - purchasing pools that negotiate health
insurance arrangements for employers and/or employees who voluntarily join. Alliances use their leverage to negotiate contracts that ensure care is
delivered in economic and equitable ways. Some have been organized by state governments, others have been privately organized. Also referred to as
health plan purchasing cooperatives. Return to Acronyms page
(HMO) Health Maintenance Organization - an entity that provides, offers or arranges for coverage of designated health services
for a fixed, prepaid premium. There are four basic models of HMOs
- Group model
- Individual practice association
- Network model
- Staff model
Under the Federal HMO Act and NAIC's Model HMO Act state and federal standards have been established to define and regulate HMO practices. Under the Federal HMO Act an entity must have three characteristics to call itself an HMO
- An organized system for providing healthcare or otherwise assuring healthcare delivery in a geographic area
- An agreed upon set of basic and supplemental health maintenance and treatment services
- A voluntarily enrolled group of people.
Return to Acronyms page
(HSA) Health Service Agreement - the document, including any related application and addenda, which specifies the benefits,
exclusions and other conditions between the health plan and the enrolling group. Return to Acronyms page
I
(IBNR) Incurred But Not Reported - costs associated with a medical service that has been provided, but for which a claim has
not yet been received by the carrier. IBNR reserves are made by a carrier to account for estimated liabilities based on studies of prior lags in claim
submissions. Return to Acronyms page
(ICD-9-CM) International Classification of Diseases, Ninth Edition (Clinical Modification) - a listing of
diagnoses and identifying codes used by physicians for reporting diagnoses of health plan enrollees. The coding and terminology provide a uniform
language that can accurately designate primary and secondary diagnoses and provide for reliable, consistent communication on claim forms.
Return to Acronyms page
(ICF) Intermediate Care Facility - a facility providing a level of care that is less than the care and treatment that a
hospital or skilled nursing facility (SNF) is designed to provide, but greater than the level of room and board.
Return to Acronyms page
(IPA) Individual Practice Association Model HMO - a healthcare model that contracts with an entity, which in turn contracts
with physicians, to provide healthcare services in return for a negotiated fee. Physicians continue in their existing individual or group practices and
are compensated on a per capita, fee schedule or fee for service basis. Return to Acronyms page
IPO) Integrated Provider Organization - a corporate umbrella for the management of a diversified healthcare delivery system.
The system may include one or more hospitals, a large group practice and/or other healthcare operations. Physicians practice as employees of the
organization or in a closely affiliated physician group. Return to Acronyms page
(IME) Independent Medical Evaluation - an examination carried out by an impartial healthcare provider, generally board
certified, for the purpose of resolving a dispute related to the nature and extent of an illness or injury.
Return to Acronyms page
J
(JCAHO) Joint Commission on Accreditation of Healthcare Organizations - an independent, private, nonprofit organization that
evaluates, sets standards for and accredits hospitals, health plans and other healthcare organizations that provide home care, mental healthcare,
ambulatory care and long-term care services. Return to Acronyms page
L
(LOS) Length of Stay - the number of days that a covered person stayed in an inpatient facility for a single admission.
Return to Acronyms page
M
(MAC) Maximum Allowable Cost List - specified multi-source prescription medications that will be covered at a generic product
price level established by a health plan. This list, distributed to participating pharmacies, is subject to periodic review and modification by the
plan. The MAC list may require covered persons to pay a price differential for a brand name product.
Return to Acronyms page
(MDC) Major Diagnostic Category - a clinically coherent grouping of ICD-9-CM diagnoses by major organ
system or etiology that is used as the first step in assignment of most diagnosis related groups (DRGs). MDCs are commonly are used
for aggregated DRG reporting. Return to Acronyms page
Medigap - a policy under which an insurer will pay a policyholder's Medicare coinsurance, deductible and co-payments for
Medicare Parts A and B and may provide additional supplemental benefits according to the supplement policy selected. Medicare supplement coverage is
state regulated and insurers may only offer ten predetermined benefit plans, referred to as "A through J." Also called Medicare wrap.
Return to Acronyms page
(Medsupp) Medicare Supplement Policy - a policy that an insurer will pay a policyholder's Medicare coinsurance, deductible
and co-payments for Medicare Parts A and B and may provide additional supplemental benefits according to the supplement policy selected. Medicare
supplement coverage is state regulated and insurers may only offer ten predetermined benefit plans, referred to as "A through J." Also called
Medigap
or Medicare wrap. Return to Acronyms page
(MSO) Management Service Organization - a legal entity that provides practice management, administrative and support services
to individual physicians or group practices. An MSO may be a direct subsidiary of a hospital or may be owned by investors.
Return to Acronyms page
N
(NCQA) National Committee for Quality Assurance - a private, nonprofit organization governed by purchasers of healthcare
(employers and government), health plans and consumers that accredits health plans and develops performance measures known as HEDIS.
Return to Acronyms page
(NDC) National Drug Code - a national classification system for the identification of drugs. Similar to the Universal Product
Code (UPC). Return to Acronyms page
(Non-Par) Non-Participating Provider - a healthcare provider who has not contracted to be a participating provider of
healthcare with the carrier or health plan. Non-par can bill the patient without balance billing limits typically agreed to by participating providers.
Also known as out of network provider. Return to Acronyms page
O
(OA) Open Access - a self-referral arrangement allowing members to see participating physicians for specialty care without a
referral from a primary care doctor or authorization from the plan. Typically found in an IPA model health plan.
Also called open panel or direct access. Return to Acronyms page
(OOA) Out of Area - coverage for treatment obtained by a covered person temporarily outside the network service area.
Return to Acronyms page
(OON) Out of Network - coverage for treatment obtained from a non-participating provider. Typically, it requires payment of a
deductible and higher co-payments and coinsurance than for treatment from a participating provider.
Return to Acronyms page
(OOPs) Out of Pocket Costs/Expenses - the portion of payments for covered health services required to be paid by the enrollee,
including co-payments, coinsurance and deductibles. Return to Acronyms page
(OTC) Over the Counter Drug - a drug that does not require a prescription under federal or state law.
Return to Acronyms page
P
(P&T) Pharmacy and Therapeutics Committee - an organized panel of physicians and pharmacists from varying practice
specialties who function as an advisory panel to the plan regarding the safe and effective use of prescription medications. It often comprises the
official organizational line of communication between the medical and pharmacy components of the health plan. A major function of such a committee is to
develop, manage and administer a drug formulary.
(PAC) Pre-Admission Certification - a review of the need for inpatient hospital care done prior to actual admission.
Established review criteria are used to determine the appropriateness of inpatient care. Return to Acronyms page
(Par) Participating Provider - a provider who has contracted with the health plan to deliver medical services to covered
persons. The provider may be a physician, hospital, pharmacy, other facility or other healthcare provider who has contractually accepted the terms and
conditions set forth by the health plan. Also known as network or in-network provider. Return to Acronyms page
(PCN) Primary Care Network - a group of primary care physicians who have joined together to share the risk of providing care to
their patients who are covered by a given health plan. Return to Acronyms page
(PCP) Primary Care Physician - a physician, the majority of whose practice is devoted to internal medicine, family/general
practice or pediatrics. An obstetrician/gynecologist sometimes is considered a primary care physician, depending on coverage.
Return to Acronyms page
(PCR) Physician Contingency Reserve - the "at risk" portion of a claim that is deducted and withheld by the health
plan before payment is made to a participating physician as an incentive for appropriate utilization and quality of care. This amount remains within the
plan and is credited to the doctor's account. The withhold can be used in instances when claims costs exceed the health plan's budget for a particular
period. The withhold may be returned to the physician in varying levels determined based on analysis of performance or productivity compared with peers.
Return to Acronyms page
(PEC) Pre-Existing Condition - any medical condition that has been diagnosed or treated within a specified period immediately
preceding the covered person's effective date of coverage. Pre-existing conditions may not be covered for some specified amount of time as defined in
the certificate of coverage (usually 6-12 months). As a result of HIPAA an individual can be required to satisfy a
pre-existing waiting period only once, as long as they maintain continuous group health plan coverage with one or more carriers.
Return to Acronyms page
(PHO) Physician-Hospital Organization - groups of physicians and/or hospitals who organize to coordinate the delivery of a
range of healthcare services to a defined population, or by directly contracting with a self-funded employer group or government program. A PHO may be
structured in a variety of forms, including a physician-owned venture, a hospital or hospital system that owns physicians' practices or a partnership
between physicians and hospitals. PHOs are sometimes called provider service networks (PSNs).
Return to Acronyms page
(PM/PM) Per Member Per Month - a formula that produces a figure describing the relationship of a specific unit relative to the
number of members per month for the length of time specified. The formula is unit/member months. For example, the actual claim dollars paid PM/PM for
January through June = total claim $ paid January through June/total membership for those six months.
Return to Acronyms page
(POS) Point of Service Plan - a health benefit plan allowing the covered person to choose to receive a service from a
participating or non-participating provider, with different benefit levels associated with the use of participating providers. Point of service can be
provided in several ways
- An HMO may allow members to obtain limited services from non-participating providers
- An HMO may provide non-participating benefits through a supplemental major medical policy
- A PPO may be used to provide both participating and non-participating levels of coverage and access, or
- Various combinations of the above
(PPO) Preferred Provider Organization - a program that establishes contracts with providers of medical care. Providers under such contracts are referred to as preferred providers. Usually, the benefit contract provides significantly better benefits and lower member cost for services received from preferred providers, thus encouraging covered persons to use these providers. Covered persons generally are allowed benefits for non-participating providers' services, usually on an indemnity basis. A PPO arrangement can be insured or self-funded. Providers may be, but are not necessarily, paid on a discounted fee for service basis. Return to Acronyms page
(PRO) Professional Review Organization - a physician sponsored organization charged with reviewing the services provided to patients. The purpose of the review is to determine if the services rendered are medically necessary; provided in accordance with professional criteria, norms and standards and provided in the appropriate setting. Return to Acronyms page
Q
(QA) Quality Assurance - a formal set of activities to review and determine the quality of services provided. Quality assurance
includes quality assessment and corrective actions to remedy any deficiencies identified in the quality of direct patient, administrative and support
services. Federal and state HMO legislation typically require plans to have formal quality assurance programs.
Return to Acronyms page
(QMB) Qualified Medicare Beneficiary - a person whose income falls below federal poverty guidelines, for whom the state must
pay the Medicare Part B premiums, deductibles and co-payments. Return to Acronyms page
R
(R&C) Reasonable and Customary - a term used to refer to the commonly charged or prevailing fees for health services within
a geographic area. A fee is considered to be reasonable if it falls within the parameters of the average or commonly charged fee for the particular
service within that specific community. Actual determination of these fees is one of the major sources of HMO knavery and abuse.
Return to Acronyms page
(Retro) Retrospective Rate Derivation - an addendum to insurance coverage that provides for risk sharing, with the employer
being responsible for all or part of that risk. The employer can be at risk for a pre-negotiated percentage of the group's healthcare cost in excess of
total premium dollars paid by the employer during the contract year. The carrier also may be required to refund to the employer a pre-negotiated
percentage of premium dollars paid if actual healthcare costs of the group are less than the premium dollars paid during the contract year. A variation
of experience-based pricing. Return to Acronyms page
S
(SCR) Standard Class Rate - a base revenue requirement on a per member or per employee basis, multiplied by group demographic
information to calculate monthly premium rates. Return to Acronyms page
(SG&A) Selling, General and Administrative Expenses - all general operating expenses except the actual cost of paid health
benefits (i.e., medical and prescription costs). Return to Acronyms page
(SNF) Skilled Nursing Facility - a facility, either freestanding or part of a hospital, that accepts patients in need of
rehabilitation and medical care of a lesser intensity than that received in a hospital. Return to Acronyms page
(SPD) Summary Plan Description - a description of the entire benefits package available to an employee as required under
ERISA
given to people covered by self-funded plans. Return to Acronyms page
(SPIN) Standard Prescriber Identification Number - a standard number could be used to identify prescribers. Under development
by the National Council of Prescription Drug Programs in conjunction with other professional organizations.
Return to Acronyms page
T
(TAT) Turnaround Time - the measure of a process cycle from the date a transaction is received to the date completed. For
claims processing, the number of calendar days from the date a claim is received to the date paid.
Return to Acronyms page
(TEFRA) Tax Equity and Fiscal Responsibility Act of 1982 - the federal law that created the risk and cost contract provisions
under which health plans contracted with HCFA and defined the primary and secondary coverage responsibilities of the Medicare
program. Superseded by the Balanced Budget Act of 1997. Return to Acronyms page
(TPA) Third-Party Administrator - an independent person or corporate entity (third-party) that administers group benefits,
claims and administration for a self-insured company or group. A TPA does not underwrite the risk.
Return to Acronyms page
U
(UB-92) Uniform Billing Code of 1992 - a revised version of UB-82, a federal directive requiring a hospital to follow specific
billing procedures, itemizing all services included and billed for on each invoice, implemented October 1, 1993.
Return to Acronyms page
(UCR) Usual, Customary and Reasonable - a term used to refer to what the payer considers the commonly charged or prevailing
fees for health services within a geographic area. A fee is considered to be reasonable if it falls within the parameters of the average or commonly
charged fee for the particular service within that specific community. What is considered reasonable by one party is not always considered reasonable by
another. Return to Acronyms page
(UM) Utilization Management - process of integrating clinical review and case management of services in a cooperative effort
with other parties, including patients, employers, providers and payers. Return to Acronyms page
(UR) Utilization Review - a formal assessment of the medical necessity, efficiency and/or appropriateness of healthcare
services and treatment plans on a prospective, concurrent or retrospective basis. Return to Acronyms page
W
(WEDI) Workgroup for Electronic Data Interchange - a taskforce formed in 1991 by the Secretary of Health and Human Services
to develop recommendations for government and industry relating to the advancement of electronic data in healthcare. WEDI's steering committee consists
of senior executives from more than 25 insurance and healthcare organizations. Return to Acronyms page