Health Care Abbreviations, Acronyms and …

1 1 1998 USA MCO, all rights reservedHealth care abbreviations , Acronyms and DefinitionsAAAHP - American Association of Health PlansAAPCC - Adjusted Average Per Capita CostThe estimated average cost of Medicare benefits for an individual in a county, based on factors of age,sex, institutional status, Medicaid, disability, and end stage renal disease status. HCFA uses theAAPCCs to make monthly payments to risk and cost - American Association of Preferred Provider OrganizationsABMS - American Board of Medical SpecialtiesAn organization formed for the purpose of assisting its member boards in their efforts to promotequality and efficiency in the process of evaluating and certifying physician - Adjusted Community RatingCommunity rating impacted by group specific demographics and the group's prior - Academy of Certified Social WorkersADA - Americans with Disabilities ActADM - Alcohol, Drug or Mental DisorderADS - Alternative Delivery SystemAn all purpose phrase generally used to cover forms of Health care delivery other than the traditionalprivate, fee-for-service.

2 Practice. PPOs, HMOs, IPAs are among the systems covered by the - American Hospital AssociationAHC - Alternative Health CareALOS - Average Length Of StayThe average number of days in a hospital for each admission. To determine ALOS, a formula is used;total patient days incurred / number of admissions and discharges during the - American Medical AssociationAMCRA - American Managed care and Review Association, see AAHPAPT - Admissions Per ThousandThe number of hospital admissions per 1,000 Health plan members. This number is determined byutilizing the formula - (# of admissions/member months) x 1,000 members x # of - Administrative Services OnlyA service requiring a third party to deliver administrative services to an employer group and requiringthe employer to be at risk for the cost of Health care services provided.

3 This is a common arrangementwhen an employer sponsors a self-funded Health care - Age/Sex RateA set of rates for a given group product in which there is a separate rate for each grouping of age andsex categories. One overall tab serves a defined group or product. These rates are used to calculatepremiums for group billing purposes. This type of premium structure is often preferred over single andfamily rating in small groups because it automatically adjusts to demographic changes in the - Ambulatory Utilization ReviewAWP - Average Wholesale PriceThe standardized cost of a pharmaceutical, calculated by averaging the cost of an undiscountedpharmaceutical charged to a pharmacy provider by a large group of pharmaceutical 1998 USA MCO, all rights reservedCCAC - Certified Alcoholism CounselorCap - CapitationIn the strictest sense, captitation is a stipulated dollar amount established to cover the cost of healthcare delivered for a person.

4 The term usually refers to a negotiated per capita rate to be paidperiodically, usually monthly, to a Health care provider. The provider is responsible for delivering orarranging for the delivery of all Health services required by the covered person under the conditions ofthe provider - Civilian Health and Medical Program of the Uniformed ServicesCMP - Competitive Medical PlanAn organization is granted this status by the federal government after they have shown they meetspecified criteria. Once this status is achieved, it enables the organization to obtain a Medicare - Certificate Of AuthorityA certificate issued by a state government, licensing the operation of a Health - Coordination Of BenefitsThe provision in a contract which applies when a person is covered under more than one groupmedical program.

5 It requires that payment of benefits will be coordinated by all programs to eliminateover-insurance or duplication of - Consolidated Omnibus Budget Reconciliation ActA federal law that requires employers to offer continued Health insurance coverage to certainemployees and their beneficiaries whose group Health insurance coverage has been - Certificate Of CoverageA description of the benefits included in a carrier's plan. The certificate of coverage is required by statelaws and represents the coverage provided under the contract issued to the employer. The certificate isprovided to the - Certificate Of NeedA certificate issued by a government body to an individual or organization proposing to construct ormodify a Health facility, acquire major new medical equipment, or offer a new or different healthservice.

6 Such issuance recognizes that a facility or service, when available, will meet the needs ofthose for whom it is - Commission on Professional and Hospital ActivitiesCPT - Current Procedural Terminology (Physician's)A list of medical services and procedures performed by physicians and other providers. Each serviceand/or procedure is identified by its own unique 5-digit - Continuous Quality ImprovementCR - Carrier ReplacementA situation where a sole carrier replaces one or more other carriers on a specific group client. Thisallows consolidation of the group's experience and - Community Rating By ClassThe practice of community rating impacted by the group's specific 1998 USA MCO, all rights reservedDDAW - Dispense As WrittenDC - Dual ChoiceA term used to describe a situation in which only two carriers are contracted by a specific - Deferred Compensation AdministratorA company that provides services through retirement planning administration, third-partyadministration, self-insured plans, compensation planning.

7 Salary survey administration and workers'compensation claims - Duplicate Coverage InquiryA request to an insurance company or group medical plan by another insurance company or medicalplan to find out whether other coverage exists for the purpose of coordination of - Durable Medical EquipmentEquipment which can stand repeated use, is primarily and customarily used to serve a medical purpose,and is appropriate for use at home. Examples include hospital beds, wheelchairs and - Doctor Of OsteopathyDOB - Date Of BirthDOH - Department Of HealthDOS - Date Of ServiceThe date on which Health care services were provided to the covered - Drug Price ReviewA weekly updating of drug prices, at average wholesale price, from the American Druggist Blue - Days Per ThousandThe number of inpatient days per 1000 Health plan members.

8 The formula is: (# of days/membermonths) x 1000 members x # of - Diagnosis Related GroupA system of classification for inpatient hospital services based on principal diagnosis, secondarydiagnosis, surgical procedures, age, sex, and presence of complications. This system of classification isused as a financing mechanism to reimburse hospital and selected other providers for - Diagnostic And Statistical Manual, 3rd Edition, RevisedAmerican Psychiatric Association's manual of diagnostic criteria and terminology, widely accepted asthe common language of mental Health clinicians and - Drug Use EvaluationSame as drug utilization review, qualitative in nature rather than - Drug Utilization ReviewA quantitative evaluation of prescription drug use, physician prescribing patterns or patient drugutilization to determine the appropriateness of drug - Diagnosis CodeEEAP - Employee Assistance ProgramServices designed to assist employees, their family members.

9 And employers in finding solutions forworkplace and personal - Electronic Data InterchangeThe computer-to-computer exchange of business or other information between two organizations. Thedata may be in either a standardized or proprietary 1998 USA MCO, all rights reservedEOB - Explanation Of BenefitsThe statement sent to covered persons by their Health plan listing services provided, amount billed, andpayment - Evidence Of InsurabilityProof presented through written statements and/or medical examination that an individual is eligiblefor a certain type of insurance coverage. This form is required for eligible persons who do not enrollduring the open enrollment period, or who apply for excess amounts of group life - End Of MonthEOMB - Explanation Of Medicare BenefitsEOY - End Of YearEPO - Exclusive Provider OrganizationA term derived from the phrase preferred provider organization (PPO).

10 However, where a PPOgenerally extends coverage for non-preferred provider services as well as preferred provider services,an EPO provides coverage only for contracted - Employee Retirement Income Security Act of 1974 This law mandates reporting and disclosure requirements for group life and Health - Fee For Service EquivalencyA quantitative measure of the difference between the amount a physician and/or other providerreceives from an alternative reimbursement system, capitation, compared to fee-for- - Fee For Service ReimbursementThe traditional Health care payment system, under which physicians and other providers receive apayment that does not exceed their billed charge for each unit of service - Flexible Spending AccountGGHAA - Group Health Association of AmericaHHCFA - Health care Financing AdministrationThe federal agency responsible for administering Medicare and overseeing states' administration 1500 - A universal billing form developed by - HCFA Common Procedural Coding SystemA listing of services.