| A | B | C | D | E | F | G | H | I | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z | |
| A | Back to Top |
| Access | A patient's ability to obtain medical care determined by factors such as the availability of medical services, their acceptability to the patient, the location of health care facilities, transportation, hours of operation, and cost of care. |
| Activities of Daily Living (ADLs) | Activities performed as part of a person's daily routine of self-care, such as bathing, dressing, toileting, and eating. Allergist - The branch of medicine concerned with the study, diagnosis and treatment of allergic manifestations. |
| Ambulatory Care | Health services delivered on an outpatient basis. If the patient makes the trip to the doctor's office or surgical center without an overnight stay, it is considered ambulatory care. |
| Ancillary Care | Additional health care services performed, such as lab work and X-rays. |
| Anesthesia | Loss of sensation resulting from pharmacologic depression of nerve function or from neurologic dysfunction. |
| Anesthetic | A compound that reversibly depresses neuronal functional, producing a loss of the ability to perceive pain and/or other sensations. |
| Anesthetist | One who administers an anesthetic. |
| Audiology | The study of hearing disorders through the identification and measurement of hearing function loss as well as the rehabilitation of persons with hearing impairments. |
| Authorization | As it applies to managed care, authorization is the approval of care, such as hospitalization. Preauthorization may be required before admission takes place or care is given by non-HMO providers. |
| B | Back to Top |
| Behavioral Health Care | Treatment of mental health and/or substance abuse disorders. |
| Benefit Levels | The limit or degree of service a person is entitled to receive based on his or her contract with a health plan or insurer. |
| Biopsy | The removal for diagnostic study of a piece of tissue from a living body. |
| Board Certified | A physician who has passed an examination given by a medical specialty board. |
| Board Eligible | A physician who has graduated from an approved medical school and is eligible to take a specialty board examination. |
| C | Back to Top |
| Cardiac stress testing | A series of electrocardiograms tracking the heart's electrical conductivity while exercising. |
| Cardiology | The medical specialty concerned with the diagnosis and treatment of heart disease. |
| Cardiologist | Physicians who specialize in the diagnosis and treatment of the heart and circulatory problems. |
| Cardiovascular disease | Diseases relating to the heart and the blood vessels or with circulation. |
| Certification | Certification is the official authorization for use of services. |
| Cervix | The constricted lower end of the uterus. |
| Cervical biopsy | Process of removing tissue from the cervix for diagnostic examination. |
| Cervical cryotherapy | The use of cold in the treatment of a disease of the cervix. |
| Chemical Dependency Services | Services and supplies used in the diagnosis and treatment of alcoholism, chemical dependency, and drug dependencies, as defined and classified by the U.S. Department of Health and Human Services. |
| Chronic Care | Care for a patient with a long-term illness. |
| Chronic Illness | An illness or disease that is long-term or permanent, as opposed to acute. Examples of chronic illness include diabetes and arthritis. |
| Claim | A demand to the insurer for the payment of benefits under the insurance contract. |
| Colitis | Inflammation of the colon. |
| Colonoscopy | Visual examination of the inner surface of the colon by means of a colonoscope. |
| Colonoscope | An elongated endoscope, usually fiberoptic. |
| Colposcopy | Examination of the vagina and cervix by means of endoscope. |
| Coding Systems-CPT-4 System | Used to identify physician services, such as injections and surgeries, for purposes of reimbursement. Coding Systems - HCPCS System - A Medicare system for identifying a whole host of services, including injectable drugs, used in physicians offices. |
| Coinsurance | The percentage of the costs of medical services paid by the patient. This is a characteristic of indemnity insurance, POS, and PPO plans. The coinsurance is usually about 20% of the cost of medical services after the deductible is paid. |
| Copayment | A type of cost sharing that requires a health plan enrollee to pay a fixed amount for a covered service. That amount is applied toward the cost of each service. A copayment is different from coinsurance in that the copayment typically does not vary according to the total cost of the service. For example, a prescription drug plan might require a copayment of $10.00 for each prescription, regardless of the actual cost of the medication. |
| Covered Services | Health care services that will be paid for, in part or whole, by an insurance plan. |
| Credentialing | Examination of a physician's or other health care provider's credentials to determine whether he or she should be entitled to clinical privileges at a hospital or to a contract with an MCO. |
| Cytology | The study of cells. |
| D | Back to Top |
| Data Retrieval | The collection of patient care data from medical records. |
| Deductible | The amount of money an insured person is required to pay for services before the insurer starts paying the bill. Deductibles are either fixed-dollar amounts or the value of specified services (such as two days of hospital care or one physician visit). Deductibles are usually tied to some reference period over which they must be incurred, for example, $100 deductible per calendar year, benefit period, or spell of illness. |
| Dermatologist | Physicians who specialize in the study of the skin, diseases of the skin and the relationship of cutaneous lesions to systemic disease. |
| Dependent | Insured's spouse, not legally separated from the insured, and unmarried children who meet certain eligibility requirements for insurance coverage and, if group insurance, who are not otherwise insured under the same group policy. The precise definition of a dependent varies by law and employee. |
| Diabetes | Any of several disorders characterized by high levels of glucose in the blood and increased urine production, especially diabetes mellitus. |
| Diagnosis | The identification of a disease or condition through examination. |
| Dietitian | An expert in the practical application of diet in the prophylaxis and treatment of a disease. |
| Disability | Any medical condition that results in functional limitations that interfere with an individual's ability to perform his or her normal work and results in limitations in major life activities. |
| Disallowance | A denial by a health care payer for portions of the claimed amount. Examples could include coordination of benefits, services that are not covered, or amounts over the fee maximum. |
| Disease Management | A philosophy toward the treatment of the patient with and illness (usually chronic in nature) that seeks to prevent recurrence of symptoms, maintain high quality of life, and prevent future need for medical resources by using an integrated, comprehensive approach to health care. Pharmaceutical care, continuous quality improvement, practice guidelines, and case management all play key roles in this effort, which (in theory) will result in decreased health care costs as well. |
| Duplication of Benefits | Overlapping or identical health coverage of an insured person under two or more plans, usually the result of contracts with different health organizations, insurance companies, or prepayment plans. |
| Durable Medical Equipment | Equipment that can be repeatedly used, is primarily and customarily used to serve a medical purpose, generally is of illness or injury, and is appropriate for use at home. Examples include hospital beds, wheelchairs, and oxygen equipment. |
| Dysfunction | Difficult or abnormal function. |
| E | Back to Top |
| ENT | The combined specialties of diseases of the ear, nose and laryn; including diseases of related structures of the head and neck. |
| Effective Date | The date on which coverage under an insurance policy begins. |
| Elective Procedure | A procedure that a patient and doctor plan in advance for a condition that is not life-threatening. |
| Electrocardiogram | A procedure used to record the potential of the electrical currents that traverse the heart and initiate its contraction. |
| Eligibility Date | The date on which a member of an insured group becomes eligible to apply for insurance under the insurance plan. |
| Eligible Dependent | A dependent of a covered employee who meets the requirements specified in the group contract to qualify for coverage. |
| Emergency Care | Medically necessary care which is immediately necessary to preserve life, prevent serious impairment to bodily functions, organs, or parts, or prevent placing the physical or mental health of the enrollee in serious jeopardy (Minnesota Rules, part 4685.0100, subpart 5A). |
| Emergicenter | A health care facility, for which the primary purpose is the provision of immediate, short-term medical care for urgent medical conditions. |
| Endoscope | An instrument for the examination of the interior or a canal or hollow viscus. |
| Episode of Care | All treatment rendered in a specified time frame for a specific disease. |
| Epithelium | The purely cellular avascular layer covering all the free surfaces, cutaneous, mucous and serous, including the glands and other structures derived therefrom. |
| Extended Care Facility | A nursing home - type setting that offers skilled, intermediate, or custodial care. |
| Extension of Benefits | A component of some insurance policies that allows medical coverage to continue past the termination date of the policy for employees not actively at work. |
| Exclusions | Charges, services, or supplies that are not covered under an insurance policy. |
| F | Back to Top |
| Family Practitioner | A medical doctor who handles primary health care in a variety of fields for individuals and families. Federal Employees Health Benefits Program (FEHBP) - The health benefits program for federal employees that is administered through the U.S. Office of Personnel Management. |
| Federally Qualified HMO | An HMO that meets certain standards mandated by the Public Health Service Act. Two of these standards include prepaid care for a fixed amount per month or year and community rating. |
| Fee for Service | Traditional provider reimbursement, in which the physician is paid according to the service performed. This is the reimbursement system used by conventional indemnity insurers. |
| Fee Schedule | A comprehensive listing of fees uses by either a health care plan or the government to reimburse physicians and/or other health care providers on a fee-for-service basis. |
| Formulary | The panel of drugs chosen by a hospital, MCO, or other health plan that is used to treat patients. Drugs outside of the formulary are only used in rare, specific circumstances. |
| G | Back to Top |
| Gatekeeper | The primary care physician in a managed care organization who determines whether an insured individual needs to see a specialist or requires other non-routine services. The goal is to guide the patient to appropriate services while avoiding unnecessary and costly referrals to specialists. |
| Generic Drug | A chemically equivalent copy designed from a brand-name drug whose patent has expired. Typically less expensive and sold under the common name for the drug, not the brand name. |
| Geriatrics | The branch of medicine concerned with the medical problems and care of the aged. |
| H | Back to Top |
| HCFA 1500 | A form developed by the Health Care Financing Administration to be used by health care providers to bill health carriers. |
| Health Care Provider Cooperative (co-op) | Authorized under Minnesota Statutes, chapter 62R, co-ops may include individual health care providers, clinics and/or hospitals organized for the purpose of marketing and delivering health care services. |
| Health Insurance | Financial protection against all or part of the medical care costs arising from disease or accidental bodily injury. Insurance may be obtained on either an individual or a group basis. |
| Health Maintenance Organization (HMO) | A nonprofit corporation organized under Minnesota Statutes, chapter 317A, or a local governmental unit as defined in subdivision 11, controlled and operated as provided in sections 62D.01 to 62D.30 which provides, either directly or through arrangements with providers or other persons, comprehensive health maintenance services to enrollees on the basis of a fixed prepaid sum without regard to the frequency or extent of services furnished to any particular enrollee (Minnesota Statutes, section 62D.02, subdivision 4). |
| Home Care | In contrast with inpatient and ambulatory care, home care is medical care ordinarily administered in a hospital or on an outpatient basis; however, the patient is not sufficiently ambulatory to make frequent office or hospital visits. In these patients, intravenous therapy, for example, is administered at the patient's residence, usually by a health care professional. Home care reduces the need for hospitalization and its associated costs. |
| Hospice | An institution that provides a centralized program of palliative and supportive services to dying persons and their families, in the form of physical, psychological, social and spiritual care; such services are provided by an interdisciplinary team of professionals and volunteers who are available at home and in specialized inpatient settings. |
| Hypertension | Elevation of the blood pressure, especially diastolic pressure. |
| I | Back to Top |
| Inpatient | A person who has been admitted to a health care facility for the purpose of receiving health care services. |
| Involution | The process of reduction of the uterus to its normal nonpregnant size and state following childbirth. |
| L | Back to Top |
| Laparoscope | An endoscope for examining the peritoneal cavity. |
| Laparoscopic surgery (laparoscopy) | Examination of the contents of the peritoneum with a laparoscope passed through the abdominal wall. |
| Legend Drug | A drug that, by law, can be obtained only by prescription and bears the label, "Caution: Federal law prohibits dispensing without a prescription." |
| Length of Stay | The number of consecutive days a patient is hospitalized. |
| Long-Term Care | Continuum of maintenance, custodial, and health services to the chronically ill or disables. Services may be provided on an inpatient (rehabilitation facility, nursing home), outpatient, or at-home basis. |
| M | Back to Top |
| Managed Care | A system to integrate the delivery and financing of comprehensive health care services to covered individuals by means of arrangement with selected health care providers; explicit criteria for the selection of health-care providers; significant financial incentives for members to use providers and procedures associated with the plan; and formal programs for quality assurance and utilization review. Providers of managed care include health maintenance organizations (HMOs) and preferred provider organizations (PPOs), as well as traditional insurance companies. |
| Maximum out-of-pocket cost/out-of-pocket limit | The maximum amount of medical costs that an insured person must pay that are not covered by the insurance policy. |
| Medicaid (Title XIX) | A federally aided, state-operated and administered program which provides medical benefits for certain indigent or low-income persons in need of health and medical care. The program is authorized by Title XIX of the Social Security Act and covers only people who meet specified eligibility covered, program eligibility, rates of payment for providers, and method of administering the program. In Minnesota, Medicaid is also called Medical Assistance. |
| Medically necessary care | Health care services appropriate, in terms of type, frequency, level, setting, and duration, to the enrollee's diagnosis or condition, and diagnostic testing and preventive services. Medically necessary care must: a) be consistent with generally accepted practice parameters as determined by health care providers in the same or similar general specialty as typically manages the condition, procedure, or treatment at issue; and b) help restore or maintain the enrollee's health; or c) prevent deterioration of the enrollee's condition; or d) prevent the reasonably likely onset of a health problem or detect an incipient problem (Minnesota Rules, part 4865.0100, subpart 9b). |
| Medicare (Title XVIII) | A U.S. health insurance program for people aged 65 and over, for people eligible for social security disability payments for two years or longer, and for certain workers and their dependents who need kidney transplantation or dialysis. Moneys from payroll taxes and premiums from beneficiaries are deposited in special trust funds for use in meeting the expenses incurred by the insured. Medicare consists of tow separate but coordinated programs: hospital insurance (Part A) and supplementary medical insurance (Part B). |
| Medicare supplemental insurance | Insurance policies that cover the costs of some health care services not covered by Medicare. Also called Medigap insurance. |
| Mesothelium | A single layer of flattened cells forming an epithelium that lines serous Cavities, pleura and pericardium. |
| Mid-level practitioners | General term for health care providers who are not physicians, including certified nurse midwifes, clinical nurse specialists, nurse practitioners, and physician assistants. |
| Minnesota Care | A comprehensive strategy to increase access to health coverage for the uninsured, contain health care costs, and improve the quality of health care services. Minnesota Care consists of three separate components: Minnesota Care, a program for the uninsured; small group and individual insurance reforms; and regulatory oversight. |
| N | Back to Top |
| Nephrology | Branch of medical science concerned with medical diseases of the kidney. |
| Network | A specific group of health care providers under contract with a health plan company. |
| Non-Participation Provider | A health care provider who is not a part of a specific health plan or network of providers. |
| Nurse Practitioner | A registered nurse specially educated and licensed to provide primary and/or specialty care including health care in homes and in ambulatory care facilities, long-term care facilities, and other health care institutions. |
| O | Back to Top |
| Obstetrics | The specialty of medicine concerned with the care of women during pregnancy, parturition, and the puerperium. |
| Open Access | Open access arrangements allow members to see participation providers, usually specialists, without referral from the health plan's gatekeeper. These types of arrangements are most often found in IPA model HMOs. |
| Open Enrollment Period | A time during which members of a group can change health plans or during which enrollees of a plan can change coverage without evidence of insurability or underwriting. |
| Ophthalmology | The medical specialty concerned with the eye, its diseases and refractive errors. |
| Oncology | Science dealing with the physical, chemical and biological properties and features of neoplasms, including causation, pathogenics, and treatment. |
| Orthopedics | Physicians who specialize in the care of the musculoskeletal system (bones, joints, muscles, tendons and ligaments). |
| Out-of Network Services | Health care services provided to health plan enrollees by providers who are not participants in that plan. |
| Out-of-Pocket Costs | Health care expenses paid by an individual which are not reimbursed by a third party. |
| Outpatient | A patient who visits a hospital or another health-care facility for a specific treatment, procedure, or test but who is not admitted to that facility. |
| Over-the-Counter (OTC) Drug | A drug product that does not require a prescription under federal or state law. |
| P | Back to Top |
| PMAP | The prepaid Medical Assistance Program (PMAP) enables the Minnesota Department of Human Services to enter into contracts with health plan companies to provide services to eligible Medical Assistance and General Assistance Medical Care recipients. Recipients who are enrolled in a prepaid health plan must receive all health care services through the plan, with the exception of emergency services. |
| Palliative | Reducing the sensitivity of; denoting the alleviation of the symptoms without curing the underlying disease. |
| Participating Providers | Health care providers who are under contract to a health care plan. |
| Parturition | Childbirth. |
| Pathology | Physicians who specialize in the interpretation of laboratory tissue and bodily fluid analysis. |
| Pathologist | A physician who practices, evaluates, or supervises diagnostic tests, using material removed from patients to determine the causes or nature of the disease. |
| Pathology specimens | A small part, or sample, of any substance or material obtained for testing. |
| Pediatrics | Medical specialty concerned with the study and treatment of children in health and disease during development, from birth through adolescence. |
| Pericardium | The fibroserous membrane, consisting of mesothelium and submesothelial connective tissue, covering the heart and beginning of the great vessels. |
| Peritoneal | Relating to the peritoneum. |
| Peritoneum | The serous sac, consisting of mesothelium and a thin layer of irregular connective tissue, that lines the abdominal cavity and covers most of the viscera contained therein. |
| Pharmacist | One who is licensed to prepare and dispense drugs and compounds and is knowledgeable concerning their properties. |
| Pharmacologic | Relating to the composition, properties and actions of drugs. |
| Physician Assistant | A health care professional certified to perform certain duties such as history taking, diagnosis, drawing blood samples, urinalysis, and injections under the supervision of a physician. |
| Pleura | The serous membrane enveloping the lungs and lining the walls of the pleural cavity. |
| Podiatry | Specialist with medical training in the disease and ailments of the foot, ankle and toes. |
| Polyp | A projecting growth from a mucus surface, as of the nose, being either a tumor or a hypertrophy of the mucus membrane. |
| Preadmission Certification | The practice of reviewing claims for hospital admission before the patient actually enters the hospital. This cost-control mechanism is intended to eliminate unnecessary hospital expenses by denying medically unnecessary admissions. |
| Preexisting Condition | A health condition that an insurance policy specifically excludes from coverage or that prevents a person from qualifying for insurance. Minnesota Statutes prohibits pre-existing condition limitations of greater than 12 months, or 18 months for late entrants. |
| Preferred Providers | Physicians, hospitals, and other health care providers who contract to provide health services to persons covered by a particular health plan. |
| Preferred Provider Organization (PPO) | PPOs are managed care organizations that offer integrated delivery systems (i.e., networks of providers) that are available through a vast array of health plans and are readily accountable to purchasers for cost, quality, access, and services associated with their networks. They use provider selection standards, utilization management, and quality assessment techniques to complement negotiated fee reductions as an effective strategy for long-term cost savings. Under a PPO benefit plan, covered individuals retain the freedom of choice of providers but are given financial incentives (i.e. lower out-of-pocket costs) to use the preferred provider network. Preferred provider organizations are marketed directly to employers as well as to insurance companies and TPAs, who then market the network to their employer clients. |
| Premium | The regular charge, usually monthly, that a policyholder or his or her employer pays to an insurer for health coverage, regardless of the policyholder's use of service. |
| Prescription | A written formula for the preparation and administration of any remedy. |
| Prescription Medication | A drug which has been approved by the Food and Drug Administration and which can, under federal or stat law, be dispensed only pursuant to a prescription order from a duly licensed physician. |
| Preventive Care | Health care that stresses healthy behavior, regular testing, screening for diseases, and other services that detect health problems early on or prevent them from occurring. |
| Primary Care | First contact and continuing care with a health care provider, including basic or initial diagnosis and treatment, health supervision, management of chronic conditions, preventive health services, and appropriate referral. Primary care is generally provided by physicians, but is increasingly provided by other personnel such as nurse practitioners or physician assistants. |
| 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 members of a given health plan. |
| Primary Care Physician or Primary Care Provider | The provider of primary care who serves as an individual's initial contact with the health care system. The primary care provider refers patients to other providers as necessary. |
| Prior authorization | A cost-control procedure in which an insurer requires a service or medication to be approved in advance in order for the service or medication to be paid for by the insurer. |
| Prophylaxis | Prevention of a disease or of a process that can lead to a disease. |
| Provider | A person or an institution that provides a health care service. |
| Psychiatry | The medical specialty concerned with the diagnosis and treatment of mental disorders. |
| Puerperium | Period from the termination of labor to complete involution of the uterus, usually defined as 42 days. |
| Pulmonary rehabilitation | Restoration of the ability of the lungs to function in a normal or near normal manner. |
| Public health | Organized community efforts aimed at the prevention of disease and promotion of health. It links many disciples and rests upon the scientific core of epidemiology (the study of disease). Core functions of public health agencies at all levels are assessment, policy development, and assurance. |
| Q | Back to Top |
| Quality Assurance (QA) | Quality assurance or quality assessment is the activity that monitors the level of care being provided by physicians, medical institutions, or any health care vendor in order to ensure that health plan enrollees are receiving the best care possible. The level of care is measured against pre-established standards, some of which are mandated by law. |
| Quality Improvement | A continuous process that identifies problems, examines solutions to those problems, and regularly monitors the solutions implemented for improvement. |
| R | Back to Top |
| Radiologist | A physician trained in the diagnostic and/or therapeutic use of X-rays and radionuclides, radiation physics, and biology. |
| Radionuclide | An isotope of artificial or natural origin that exhibits radioactivity. |
| Referral | The recommendation by a physician and/or health plan for a member to receive care from a different physician or facility. |
| Respite Care | Assistance given a primary health care giver to alleviate stress, such as providing substitute or relief patient care. |
| S | Back to Top |
| Secondary Care | Health care services provided by medical specialists who generally do not have first contact with patients, but instead are referred to them by primary care and physicians. |
| Skilled Nursing Facility | Nursing home services eligible for payment under Medicare. |
| Specialty physician | A licensed physician, either employed by or under contract with the health plan company, who has specialized education, training, or experience (Minnesota Rules, part 4685.01000, subpart 13a). |
| Spend down | The amount of health care costs an individual must incur in order to qualify for Medicaid. That amount is determined on a case-by-case basis. |
| Splanchnology | The branch of medical science dealing with the viscera (viscus). |
| Surgicenter | A separate, freestanding medical facility specializing in outpatient or same-day surgical procedures. Surgicenters drastically reduce the costs associated with hospitalization for routine surgical procedures because extended inpatient care in not required for specific disorders. |
| T | Back to Top |
| Third Party Payer | A public or private organization that pays for or underwrites coverage for health care expenses. |
| Trauma center | Designated, inpatient facility designed to provide specialized treatment for people who have experienced a physically damaging catastrophic event. The main focus of such centers is prompt, often emergency, treatment in order to prevent further damage and increase chances for recovery. |
| Triage | A term that originated on the battlefield, triage is the evaluation of patient conditions for urgency and seriousness, and establishment of a priority list for multiple patients. In the setting of managed care, triage is often performed after office hours on the telephone by a nurse or other health professional to screen patients for emergency treatments. |
| U | Back to Top |
| Ulcerative | Causing the formation of ulcers. |
| Urgent Care Center | A medical facility where ambulatory patients can be treated on a walk-in basis, without an appointment, and receive immediate non-emergency care. The urgent care center may be open 24 hours a day; patients calling an HMO after hours with urgent, but not emergent clinical problems are not often referred to these facilities. |
| Urgently Needed Care | Medically necessary care which does not meet the definition of emergency care but is needed as soon as possible, usually within 24 hours (Minnesota Rules, part 4865.0100, subpart 16). |
| Urogenital | Relating to the organs of reproduction and urination. |
| Urologist | Medical specialty concerned with the study, diagnosis and treatment of diseases of the genitourinary tract. |
| V | Back to Top |
| Viscus | An organ of the digestive, respiratory, urogenital, and endocrine systems as well as the spleen, the heart, and the great vessels; hollow and multilayered walled organs studied in splanchnology. |
| W | Back to Top |
| Workers' compensation | Liability insurance requiring certain employers to pay benefits and furnish medical care to employees for on-the-job injuries, and to pay benefits to dependents of employees killed by occupational accidents. |
| X | Back to Top |
| Xanthoma | A yellow papule or nodule in the skin, containing lipid deposits. |
| Xerosis | Abnormal dryness of the skin, eyeballs, or mucus membranes. |
| X-ray | Electromagnetic radiation that has the capabilities of penetrating solids. |
| Y | Back to Top |
| Yeast | A fungi found in the body. |
| Z | Back to Top |
| Zinc ointment | An ointment composed of mineral oil and zinc oxide, used as a sunblock and to treat skin conditions. |
| Zymosis | An infectious or contagious disease. |
The Following is a List
of Useful HealthCare Terms
These terms are used within the hospial and clinic, and are provided here to assist you in understanding the terminolgy.