CCMC Glossary of Terms Flashcards
AAPM&R
American Academy of Physical Medicine and Rehabilitation
ACCESS TO CARE
The ability and ease of clients to obtain healthcare when they need it.
ACCESSIBLE
A term used to denote building facilities that are barrier-free thus enabling all
members of society safe access, including persons with physical disabilities.
ACCOUNTABLE CARE
ORGANIZATION (ACO)
A set of healthcare providers including primary care physicians, specialists, and
hospitals that work together collaboratively and accept collective accountability
for the cost and quality of care delivered to a population of patients. ACOs became popular in the Medicare fee-for-service benefit system as a result of the Affordable Care Act. ACOs are formed around a variety of existing types of
provider organizations such as multispecialty medical groups, physician-hospital
organizations (PHO), and organized or integrated delivery systems.
ACCREDITATION
A standardized program for evaluating healthcare organizations to ensure a
specified level of quality, as defined by a set of national industry standards. Organizations that meet accreditation standards receive an official authorization
or approval of their services. Accreditation entails a voluntary survey process that
assesses the extent of a healthcare organization’s compliance with the standards
for the purpose of improving the systems and processes of care (performance) and, in so doing, improving client outcomes.
ACTIONABLE TORT
A legal duty, imposed by statute or otherwise, owing by defendant to the one injured.
ACTIVE LISTENING
A structured way of communication and interacting in which one is actively
engaged with the speaker primarily through focused attention and suspension
of one’s own frame of reference, biases, distractions and judgment. A communication technique that improves personal relationships, fosters
understanding, and facilitates cooperation and collaboration and eliminates conflict.
ACTIVITIES OF DAILY LIVING
(ADLS)
Routine activities an individual tends to do every day for self-care and normal living. These include eating, bathing, grooming, dressing, toileting, transferring (such as walking, bed to chair) and continence. Assessment of an individual’s ability to perform these ADLs is important for determining an individual’s ability, independence, disability or limitations. This assessment determines the type of long-term care and benefit coverage the individual needs. care may include placement in a nursing home, skilled care facility or home care services. Benefit
coverage may include Medicare, Medicaid or long-term care insurance.
ACTIVITY LIMITATIONS
Difficulties an individual may have in executing activities. An activity limitation may range from a slight to a severe deviation in terms of quality or quantity in executing the activity in a manner or to the extent that is expected of people without the health condition.
ACTUAL VALUE
Also referred to as real value. Measures the worth one derives from using or consuming a good, product, service or an item, and represents the utility of the good, product, service, or item.
ACTUARIAL STUDY
Statistical analysis of a population based on its utilization of healthcare services
and demographic trends of the population. Results used to estimate healthcare
plan premiums or costs.
ACTUARY
A trained insurance professional who specializes in determining policy rates, calculating premiums, and conducting statistical studies.
ACUITY
Complexity and severity of the client’s health/medical condition.
ACUTE CARE
The acute care delivery systems focus on treating sudden and acute episodes of illness such as medical and surgical management or emergency treatment, which otherwise cannot be taken care of in a less intense care setting. Acute
care settings may include hospitals, acute rehabilitation centers, emergency care,
transitional hospitals, and follow-up long-term disease management settings.
ADA
Americans with Disabilities Act of 1990
ADA AMENDMENTS ACT
(ADAAA)
Americans with Disabilities Act Amendments Act of 2008
ADL
Activities of Daily Living. Routine activities carried out for personal hygiene and health and for operating a household. ADLs include feeding, bathing, showering, dressing, getting in or out of bed or a chair, and using the toilet.
ADAPTIVE BEHAVIOR
The effectiveness and degree to which an individual meets standards of self-
sufficiency and social responsibility for his/her age-related cultural group.
ADHERENCE
“The extent to which a person’s behaviour–taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations
[e.g., health regimen] from a health care provider” (Sabate, 2003).
ADHESIVE CONTRACT
A contract between two parties where one party with stronger bargaining power sets the terms and conditions and the other party, which is the weaker of the two with little to no ability to negotiate, must adhere to the contract and is placed in a “take it or leave it” position
ADJUSTED CLINICAL GROUP®
(ACG) SYSTEM:
Developed by the School of Public Health at Johns Hopkins University, this system clusters clients into homogenous groups (102 discrete groups) based on a unique approach to measuring morbidity to ultimately improve accuracy and fairness in evaluating healthcare provider performance, identifying clients at high risk, forecasting healthcare utilization, and setting equitable payment structure and
rates for the providers of care. The System accounts for the burden of morbidity in a client population based on disease patterns, age, and gender and relies on the diagnostic and/or pharmaceutical code information found in insurance claims or other computerized client health records
ADJUSTER
A person who handles claims (also referred to as Claims Service Representative).
ADLS
See activities of daily living.
ADMINISTRATIVE LAW
That branch of public law that deals with the various organizations of federal,
state, and local governments which prescribes in detail the manner of their
activities.
ADMINISTRATIVE SERVICES
ONLY (ASO)
An insurance company or third party administrator (TPA) that delivers administrative services to an employer group. This usually requires the employer
to be at risk for the cost of healthcare services provided, which the ASO processes and manages claims.
ADMISSION CERTIFICATION
A form of utilization review in which an assessment is made of the medical necessity of a client’s admission to a hospital or other inpatient facility. Admission certification ensures that clients requiring a hospital-based level of care and length of stay appropriate for the admission diagnosis are usually assigned and certified and payment for the services are approved.
ADMISSION REVIEW
A review that occurs within 24 hours of a client’s admission to a healthcare facility (e.g., a hospital) or according to the time frame required in the contractual
agreement between the healthcare provider and the health insurance plan. This
review ensures that the client’s care in an inpatient setting is necessary, based on the client’s health condition and intensity of the services needed.
ADVANCE DIRECTIVE
Legally executed document that explains the client’s healthcare related wishes and decisions. It is drawn up while the client is still competent and is used if the
client becomes incapacitated or incompetent.
ADVERSE EVENTS
Any untoward occurrences, which under most conditions are not natural consequences of the client’s disease process or treatment outcomes.
ADVOCACY
The act of recommending, pleading the cause of another; to speak or write in favor of.
ADVOCATE
A person or agency who speaks on behalf of others and promotes their cause.
AFFECT
The observable emotional condition of an individual at any given time.
AFFIDAVIT
A written statement of fact signed and sworn before a person authorized to administer an oath.
AGGREGATED DIAGNOSIS
GROUPS (ADGS)
A grouping of diagnosis codes that are similar in terms of severity and likelihood of persistence in a client’s health condition over time. An individual client can suffer more than one health condition and therefore may have more than one ADG (total of 32 ADG clusters). Individual diseases or conditions are placed into a single ADG based on a set of criteria including likely persistence of
diagnosis, severity of illness, etiology, diagnostic certainty, and need for specialty care interventions. This system was developed by the Bloomberg School of Public Health at Johns Hopkins University
AGREED MEDICAL
EXAMINATION
An evaluation conducted by a provider who is selected by agreement between an injured workers’ attorney and the insurance claims administrator and/or attorney. The parties agree to conduct a medical examination and prepare a medical- legal report to help resolve an existing dispute. The evaluation also serves to determine what portions of the work-related injury have contributed to the disability and
what portions have resulted from other sources or causation.
AHA
American Heart Association
AHRQ
Agency for Healthcare Research and Quality
ALGORITHM
The chronological delineation of the steps in, or activities of, client care to be applied in the care of clients as they relate to specific conditions/situations.
ALTERNATE LEVEL OF CARE
A level of care that can safely be used in place of the current level and determined based on the acuity and complexity of the client’s condition and the type of needed services and resources.
AMA
American Medical Association
AMBULATORY PAYMENT
CLASSIFICATION (APC)
SYSTEM
An encounter-based classification system for outpatient reimbursement, including hospital-based clinics, emergency departments, observation, and ambulatory
surgery. Payment rates are based on categories of services that are similar in cost and resource utilization.
ANA
American Nurses Association
ANCC
American Nurses Credentialing Center
ANCILLARY SERVICES
Other diagnostic and therapeutic services that may be involved in the care of clients other than nursing or medicine. Includes respiratory, laboratory, radiology,
nutrition, physical and occupational therapy, and pastoral services.
APC
Ambulatory Payment Classification.
APPEAL (CARE PROVISION
RELATED)
The formal process or request to reconsider a decision made not to approve an admission or healthcare services, reimbursement for services rendered, or a client’s request for postponing the discharge date and extending the length of
stay.
APPEAL (LEGAL IN NATURE)
The process whereby a court of appeals reviews the record of written materials from a trial court proceeding to determine if errors were made that might lead to a reversal of the trial court’s decision.
APPROPRIATENESS OF
SETTING
Used to determine if the level of care needed is being delivered in the most appropriate and cost-effective setting possible.
APPROVAL
To offer or receive affirmation, sanction, or agreement about a decision, action, service, treatment, or intervention. In the area of health insurance, it is the
act of authorizing or affirming a service to a client that implies agreement to be responsible for reimbursing the provider of the service the related cost of
providing the service to a client/support system.
APPROVED CHARGE
The amount Medicare pays a physician based on the Medicare fee schedule. Physicians may bill the beneficiaries for an additional amount, subject to the
limiting charge allowed.
ASO
Administrative Services Only
ASSESSING
The process of collecting in-depth information about a person’s situation and
functioning to identify individual needs in order to develop a comprehensive case management plan that will address those needs. In addition to direct client contact, information should be gathered from other relevant sources
ASSIGNMENT OF BENEFITS
Paying medical benefits directly to a provider of care rather than to a member. This system generally requires either a contractual agreement between the health plan and provider or written permission from the subscriber for the provider to bill
the health plan.
ASSISTIVE DEVICE
Any tool that is designed, made, or adapted to assist a person to perform a particular task.
ASSISTIVE TECHNOLOGY
Any item, piece of equipment, or product system, whether acquired commercially
or off the shelf, modified, or customized, that is used to increase, maintain, or
improve functional capabilities of individuals with disabilities.
ASSISTIVE TECHNOLOGY
SERVICES
Any service that directly assists an individual with a disability in the selection, acquisition, or use of an assistive technology device.
ASSUMPTION OF RISK
A doctrine based upon voluntary exposure to a known risk. It is distinguished from contributory negligence, which is based on carelessness, in that it involves a
comprehension that a peril is to be encountered and a willingness to encounter it.
ASSURANCE/INSURANCE
The term assurance is used more commonly in Canada and Great Britain. The term insurance is the spreading of risk among many, among whom few are likely to
suffer loss. The terms are generally accepted as synonymous.
AUTHORIZATION
The approval of client care services, admission, or length of stay by a health benefit plan (e.g., HMO, PPO) based on information provided by the healthcare
provider.
AUTONOMY
Agreement to respect another’s right to self-determine a course of action; support of independent decision making.
BAD FAITH
Generally involving actual or constructive fraud, or a design to mislead or deceive another.
BARRIER-FREE
A physical, manmade environment or arrangement of structures that is safe and accessible to persons with disabilities.
BARRIERS
Factors in a person’s environment that, if absent or present, limit one’s functioning
and create disability. Examples are a physical environment that is inaccessible, lack of relevant assistive technology, and negative attitudes of people toward disability. Barriers also include services, systems, and policies that are either
nonexistent or that hinder the involvement of people with a health condition in any area of life.
BAS
Burden Assessment Scale
BENCHMARKING
An act of comparing a work process with that of the best competitor. Through this process one is able to identify what performance measure levels must be surpassed. Benchmarking assists an organization in assessing its strengths and weaknesses and in finding and implementing best practices.
BENEFICENCE
Compassion; taking positive action to help others; desire to do good; core principle of client advocacy.
BENEFICIARY
An individual eligible for benefits under a particular plan. In managed care organizations beneficiaries may also be known as members in HMO plans or
enrollees in PPO plans.
BENEFIT PACKAGE
The sum of services for which a health plan, government agency, or employer contracts to provide. In addition to basic physician and hospital services, some plans also cover prescriptions, dental, and vision care.
BENEFIT PROGRAMS
government agency, or employer to individuals based on some sort of an agreement between the parties; for example between an employer and an employee. Benefits vary based on the plan and may include physician and hospital services, prescriptions, dental and vision care, workers’ compensation, long-term
care, mental and behavioral health, disability and accidental death, counseling and other therapies such as chiropractor care.
BENEFITS
Principal Term: The type of health and human services covered by an insurance
company/health plan and as agreed upon between the plan/insurance company
and the individual enrollee or participant. Benefits also refers to the amount payable by an insurance company to a claimant or beneficiary under the claimant’s specific coverage as stipulated in the agreed upon health plan.
BEYOND (OUTSIDE)-THE-
WALLS CASE MANAGEMENT
Models where healthcare resources, services and case managers are based externally to an acute care/hospital setting, that is in the community.
BOARD-CERTIFIED CASE
MANAGER
A case manager who has earned the certified case manager (CCM) credential offered by the Commission for Case Manager Certification (CCMC). This involves passing an evidence-based certification examination after meeting a set of criteria
that qualifies the case manager to sit for the examination. Once certified, the case manager must maintain the certification by acquiring ongoing education
through means of continuing education units (CEUs), and uphold the CCM Code of Professional Conduct for Case Managers.
BODY OF KNOWLEDGE (BOK)
Widely recognized information, standards, methods, tools, and practices about a specific field. A BOK usually includes a comprehensive set of concepts,
terms, tools, and activities that make up a profession, as defined by a relevant professional society. While the term body of knowledge is used to describe
the document that defines that knowledge, the body of knowledge itself is a dynamic reference that “is more than simply a collection of terms and concepts;
a professional reading list; a library; a website or a collection of websites; a description of professional functions; or even a collection of information”. Therefore, one may then describe a BOK as a prescribed
aggregation of essential knowledge in a particular field or specialty an individual within the field is expected to have mastered to effectively practice and be considered a practitioner within the specialty
BOK
Body of Knowledge
BONA FIDE
Literally translated as “in good faith.”
BRAIN DISORDER
A loosely used term for a neurological disorder or syndrome indicating impairment or injury to brain tissue.
BRAIN INJURY
Any damage to tissues of the brain that leads to impairment of the function of the Central Nervous System.
BURDEN OF PROOF
The duty of producing evidence as the case progresses, and/or the duty to establish the truth of the claim by a preponderance of the evidence. The former may pass from party to party, the later rests throughout upon the party asserting the affirmative of the issue.
CAPACITY
A construct that indicates the highest probable level of functioning a person may reach. Capacity is measured in a uniform or standard environment, and thus reflects the environmentally adjusted ability of the individual.
CAPITATION
A fixed amount of money per-member-per-month (PMPM) paid to a care provider for covered services rather than based on specific services provided. The typical reimbursement method used by HMOs. Whether a member uses the health service once or more than once, a provider who is capitated receives the same payment.
CAPTIVE
An insurance company formed by an employer to assume its workers’ compensation and other risks, and provide services.
CARE CONTINUUM ALLIANCE
Previously known as the Disease Management Association of America (DMAA).
CARE COORDINATION
The deliberate organization of patient care activities between two or more participants (including the patient) involved in patient’s care to facilitate the
appropriate delivery of health care services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required
patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care”.
CARE COORDINATION HUB
The context of delivering integrated healthcare services to clients/support systems with special emphasis on collaboration, coordination and communication among multiple healthcare providers, care settings and agencies in an attempt to ensure client’s safety and the provision of quality, cost-effective case management services.
CARE GUIDELINES
Nationally recognized and professionally supported plans of care recommended for the care management of clients with a specific diagnosis or health condition and in a particular care setting. Usually developed based on the latest available evidence and modified as necessary by healthcare professionals upon
implementation for the care of an individual client.
CARE MANAGEMENT
A healthcare delivery process that helps achieve better health outcomes by anticipating and linking clients with the services they need more quickly. It also helps avoid unnecessary services by preventing medical problems from escalating.
CARE SETTING
See also practice setting, level of care. A place across the continuum of health and human services where a client may receive healthcare services dependent on need. Care settings vary based on intensity and complexity of the services
provided to clients; that is, from least complex (e.g., prevention and wellness) to most complex (e.g., acute and critical care services).
CAREGIVER
Principal Term: The person responsible for caring for a client in the home setting. Can be a family member, friend, volunteer, or an assigned healthcare professional.
CARF
Commission on Accreditation of Rehabilitation Facilities. A private, non-profit organization that establishes standards of quality for services to people with disabilities and offers voluntary accreditation for rehabilitation facilities based on a set of nationally recognized standards.
CARPAL TUNNEL SYNDROME
The name given to the symptoms that occur when the nerves and tendons running through the carpal tunnel of the wrist are compressed by tissue or bone
or become irritated and swell. The carpal tunnel itself is a narrow passage in the wrist comprised of bones and ligaments through which nerves and tendons pass into the hand. Also referred to as “Cumulative Trauma Injury/Disorder,”
“Repetitive Motion Injury,” and “Repetitive Stress Syndrome.”
CARRIER
The insurance company or the one who agrees to pay the losses. A carrier may be organized as a company, either stock, mutual, or reciprocal, or as an Association or Underwriters.
CARVE OUT
Services excluded from a provider contract that may be covered through arrangements with other providers. Providers are not financially responsible for
services carved out of their contract.
CASE-BASED REVIEW
The process of evaluating the quality and appropriateness of care based on the review of individual medical records to determine whether the care delivered is acceptable. It is performed by healthcare professionals assigned by the hospital or an outside agency.
CASE CLOSURE
Terminating the provision of case management services to aclient/support system.
The process of communicating the decision to terminate services to clients/support
systems, payor representative, and other healthcare professional involved.
CASE CONFERENCE
A multidisciplinary healthcare team meeting that is held to discuss a client or client’s support system situation such as conflict in decision making between the
client and client’s support system, clarification of plan of care and prognosis, end of life issues, or an ethical dilemma. Depending on the purpose of the conference, the client and client’s support system may or may not participate in the meeting. Other participants are the case manager, social worker, physician of record or primary care provider, specialty care provider, registered nurse, registered dietitian, physical therapist, occupational therapist, ethicist (if the purpose is an
ethical dilemma) and others as necessary.
CASE LAW
The aggregate of reported cases forming a body of jurisprudence, or the law of a particular subject as evidenced or formed by the adjudged cases, in distinction to
statutes and other sources of law.
CASE MANAGEMENT
Case Management is a dynamic process that assesses, plans, implements, coordinates, monitors, and evaluates to improve outcomes, experiences, and value.
The practice of case management is professional and collaborative, occurring in a
variety of settings where medical care, mental health care, and social supports are delivered. Services are facilitated by diverse disciplines in conjunction with the care recipient and their support system.
In pursuit of health equity, priorities include identifying needs, ensuring appropriate access to resources/services, addressing social determinants of health and facilitating safe care transitions. Professional case managers help navigate complex systems to achieve mutual goals, advocate for those they serve, and recognize personal dignity, autonomy, and the right to self-determination.
CASE MANAGEMENT BODY
OF KNOWLEDGE (CMBOK)
A comprehensive resource of essential knowledge in the field of case management that a case manager is expected to master and become knowledgeable, skilled, as well as experienced in, to effectively care for clients and their support systems and be considered a competent case management practitioner.
CASE MANAGEMENT
DEPARTMENT
A division within a healthcare organization (e.g., provider, employer, or payor) responsible for the provision of case management services to clients and their support systems.
CASE MANAGEMENT MODEL
A conceptual or graphic representation of the practice of case management in an organization. It usually depicts the relationships among the key functions and stakeholders of case management, and the roles and responsibilities of case managers.
CASE MANAGEMENT PLAN
A timeline of patient care activities and expected outcomes of care that address the plan of care of each discipline involved in the care of a particular patient. It is usually developed prospectively by an interdisciplinary healthcare team in relation to a patient’s diagnosis, health problem, or surgical procedure.
CASE MANAGEMENT PLAN
OF CARE
Principal Term: A comprehensive plan of care for an individual client that describes the
(1) problems, needs and desires determined based upon findings of the client’s assessment;
(2) strategies such as treatments and interventions to be instituted to address the problems and needs; and
(3) measurable goals including
specific outcomes to be achieved to demonstrate resolution of the problems and needs, the timeframe(s) for achieving them, the resources available and to be
used to realize the outcomes, and the desires/motivation of the client that may have an impact on the plan.
CASE MANAGEMENT
PROCESS
Principal Term: The context in which case managers provide health and human services to clients and their support systems. The process consists of several steps or sub- processes that are iterative, cyclical and recursive rather than linear
in nature and applied until the client’s needs and interests are met. The steps include screening, assessing, stratifying risk, planning, implementing, following-up, transitioning, post-transitioning communication, and evaluating outcomes. The
process, with special intervention by case managers, work together with clients and their support systems to evaluate and understand the care options available to the clients; identify what is best to meet their needs; and institute action to achieve their goals and meet their interests and expectations.
CASE MANAGEMENT
PROGRAM
An organized approach to the provision of case management services to clients and their support systems. The program is usually described in terms of (1) vision, mission and objectives; (2) number and type of staff including roles, responsibilities and expectations; and (3) a specific model or conceptual
framework that delineates the key case management functions which may include clinical care management, transitional planning, resources utilization and management, bed capacity management, clinical documentation enhancement,
quality and variance/delays management and others depending on the healthcare
organization.
CASE MANAGER
Principal Term: A health and human servcies professional who is responsible for coordinating the overall care, services and resources delivered to an individual client or a group of clients and their support systems based on the client’s health
and human services issues, needs and interests.
CASE MIX COMPLEXITY
An indication of the severity of illness, prognosis, treatment difficulty, need for intervention, or resource intensity of a group of clients.
CASE MIX GROUP (CMG)
Each CMG has a relative weight that determines the base payment rate for inpatient rehabilitation facilities under the Medicare system.
CASE MIX INDEX (CMI)
The sum of DRG-relative weights of all patients/cases seen during a 1-year period in an organization, divided by the number of cases hospitalized and treated during the same year.
CASE RATES
Rate of reimbursement that packages pricing for a certain category of services. Typically combines facility and professional practitioner fees for care and services.
CASE RESERVE
The dollar amount stated in a claim file which represents the estimate of the amount unpaid.
CASUALTY INSURANCE
A general class of insurance and workers’ compensation insurance.
CATASTROPHIC CASE
Any medical condition or illness that has heightened medical, social and financial consequences that responds positively to the control offered through a systematic effort of case management.
CATASTROPHIC CASE
MANAGEMENT
Specialized and intricate services reflective of the needs of individuals with complex and life-altering conditions (e.g., severe injury, multiple comorbidities,
and permanent disabilities). Often catastrophic case management includes a
full spectrum of services for the individual or worker with a catastrophic injury or illness – sometimes including both disability case management and life care planning.
CATASTROPHIC ILLNESS
Any medical condition or illness that has heightened medical, social, and financial consequences and responds positively to the control offered through a systematic effort of case management services.
CATASTROPHIC INJURY
A serious injury that results in severe and long-term effects on the individual who sustains it, including permanent severe functional disability. Examples are traumatic brain, spine, or spinal cord injury; multiple trauma; and loss of major
body parts.
CCMC
Commission for Case Manager Certification
CERTIFIED NURSE LIFE CARE
PLANNER (CNLCP)
A registered professional nurse who holds a board certification from the Certified Nurse Life Care Planner Certification Board. This health professional develops a client-specific lifetime plan of care, while applying the nursing process. The plan employs a comprehensive and evidence-based approach in the estimation of current and future healthcare needs of the client. Also included are the associated
costs and frequencies of items and services.
CERTIFIED VOCATIONAL
EVALUATOR (CVE)
A professional specialized in vocational assessment and rehabilitation who has the
met the minimum requirements for nationally recognized voluntary certification.
CERTIFIED VOCATIONAL
REHABILITATION PROVIDER
A vocational rehabilitation practitioner who is registered in the workers’ compensation agency or commission in the state/jurisdiction of employment.
This registration certifies that the rehabilitation practitioner is certified to provide vocational rehabilitation services to individuals with disabilities.
CHANGE MANAGEMENT
A structured and systematic approach or process organized to move an organization, program, or team of individuals from a current to a future desired state. The process employs strategies and tools similar to project management
through which change is formally introduced with a clearly stated goal. Some of the tactics applied in the change management process include but are not limited to ways to do the following: (1) communicate effectively, (2) empower staff, (3)
minimize resistance, (4) enhance adoption of change, (5) establish and execute a roadmap for change, (6) ensure sustainability, and (7) achieve success. Change
management is an organizational mandate that entails thoughtful planning, sensitive implementation, and consultation with – and involvement of – the people
affected by the change.
CHRONIC CARE MODEL
A systems model that proposes several basic and specific elements for improving
care in health systems at the community, organization, practice, and individual client levels. It ensures delivery of high-quality chronic disease care to clients with chronic illnesses. The elements of the model include the community, health system, self-management support, delivery system design, decision support, and use of clinical information systems. Evidence-based practices in each of
these elements foster productive interactions between informed clients/support systems and their providers.
CLAIMANT
One who seeks a claim or one who asserts a right or demanding a legal proceeding.
CLAIMS ADJUSTER
An insurance professional who investigates claims by interviewing the claimant
and other involved parties (e.g., employers and witnesses), reviews related records to determine degree of liability and damages, and assures that an
insurance policy exists and covers the claimed damages. In healthcare, a claims adjuster also assures that medical care is available to the worker as needed based on the injury or occupational illness.
CLAIMS SERVICE
REPRESENTATIVE
A person who investigates losses and settles claims for an insurance carrier or the insured. A term preferred to adjuster.
CLIENT SOURCE
The way a case manager comes in contact with a client to provide case management services, usually taking place either by a referral from another healthcare provider, the client or a member of the client’s support system. In
some case management programs, client source may be based on screening of the client during a healthcare encounter; in other organizations it is only based on a referral.
CLIENT-RELATED OUTCOMES
Consequences or results of care activities, processes, or services that are directly related to the client’s condition, health status, and/or situation.
CLINICAL REVIEW CRITERIA
The written screens, decision rules, medical protocols, or guidelines used to evaluate medical necessity, appropriateness, and level of care.
CMAG
Case Management Adherence Guidelines
CMBOK
Case Management Body of Knowledge.
CMG
Case Mix Group
CMI
case mix index.
CMS
Centers for Medicare & Medicaid Services: Formerly known as the Health Care Financing Administration (HCFA).
CMSA
Case Management Society of America
COB
Coordination of Benefits
COBRA
Consolidated Omnibus Budget Reconciliation Act
CODING
A mechanism of identifying and defining client care services/activities as primary
and secondary diagnoses and procedures. The process is guided by the ICD-9-CM coding manual, which lists the various codes and their respective descriptions. Coding is usually done in preparation for reimbursement for services provided.
COGNITIVE REHABILITATION
Therapy programs which aid persons in managing specific problems in perception, memory, thinking and problem- solving. Skills are practices and strategies are taught to help improve function and/or compensate for remaining deficits.
COINSURANCE
A type of cost sharing in which the insured person pays or shares part of the medical bill, usually according to a fixed percentage.
COLLABORATION
A process where two or more individuals work closely or jointly together to achieve a mutual goal or purpose such as resolving a problem or improving a
situation. This process requires openess, mutual trust and respect, sharing of knowledge and consensus.
COLLABORATIVE CARE
An evidence-based approach that involves the provision of mental health, behavioral health, and substance use services within a primary care setting.
COMMISSION ON
ACCREDITATION OF
REHABILITATION FACILITIES
(CARF)
A private non-profit organization that establishes standards of quality for services to people with disabilities and offers voluntary accreditation for rehabilitation facilities based on a set of nationally recognized standards.
COMMON LAW
A system of legal principles that does not derive its authority from statutory law, but from general usage and custom as evidenced by decisions of courts.
COMMUNITY ALTERNATIVES
Agencies, outside an institutional setting, which provide care, support, and/or services to people with disabilities.
COMMUNITY ASSESSMENT
RISK SCREEN (CARS)
An assessment tool used to determine the risk for rehospitalization or emergency
department admittance of elderly clients. The tool focuses on the client’s current health status and lifestyle behaviors similar to the health risk assessment (HRA) tool
COMORBIDITY
A preexisting condition (usually chronic) that, because of its presence with a specific condition, causes an increase in the length of stay by about 1 day in 75% of the clients.
CONCURRENT REVIEW
A method of reviewing client care and services during a hospital stay to validate the necessity of care and to explore alternatives to inpatient care. It is also a form
of utilization review that tracks the consumption of resources and the progress of clients while being treated.
CONDITIONAL
REHABILITATION
PROFESSIONAL
A rehabilitation professional who has not yet met all of the requirements to be a qualified rehabilitation professional.
CONTEMPT OF COURT
Any act that is calculated to embarrass, hinder, delay or obstruct the court in the
administration of justice, or that is calculated to lessen its authority of its dignity.
CONTINUED STAY REVIEW
A type of review used to determine that each day of the hospital stay is necessary and that care is being rendered at the appropriate level. It takes place during a client’s hospitalization for care.
CONTINUOUS QUALITY
IMPROVEMENT (CQI)
A key component of total quality management that uses rigorous, systematic, organization-wide processes to achieve ongoing improvement in the quality of
healthcare services and operations. It focuses on both outcomes and processes of care.
CONTINUUM OF CARE
The continuum of care matches ongoing needs of the individuals being served by the case management process with the appropriate level and type of health, medical, financial, legal and psychosocial care for services within a setting or
across multiple settings.
CONTRACTOR
A business entity that performs delegated functions on behalf of the organization.
CONTRACTUAL ETHICS
Terms and conditions in a contract that are ethical in context and must be adhered to by the involved parties. Sometimes these terms are not explicit and impose moral rather than legal obligations, for example, undue influence and
informed consent.
COORDINATION OF BENEFITS
(COB)
An agreement that uses language developed by the National Association of Insurance Commissioners and prevents double payment for services when a subscriber has coverage from two or more sources.
CORE THERAPIES
Basic therapy services provided by professionals on a rehabilitation unit. Usually refers to nursing, physical therapy, occupational therapy, speech-language pathology, neuropsychology, social work and therapeutic recreation.
CORF
Comprehensive Outpatient Rehabilitation Facility
COST-BENEFIT ANALYSIS
A technique or systematic process used to calculate and compare the benefits and costs of an action, intervention, service or treatment, and to determine how well, or how poorly, it will turn out. This analysis reveals whether the benefits outweigh
the costs, and by how much so that the involved party is able to make appropriate decision(s).
CPR
Computer-based patient record
CPT
Current procedural terminology: A listing of descriptive terms and identifying codes for reporting medical services and procedures performed by health care providers and usually used for billing purposes.
CQI
Continuous Quality Improvement
CREDENTIALING
A review process to approve a provider who applies to participate in a health
plan. Specific criteria are applied to evaluate participation in the plan. The review may include references, training, experience, demonstrated ability, licensure
verification, and adequate malpractice insurance.
CROSS EXAMINATION
The questioning of a witness during a trial or deposition by the party opposing those who originally asked him/her to testify.
CUSTODIAL CARE
Money awarded by a court to someone who has been injured (plaintiff) and that must be paid by the party responsible for the injury (defendant). Normal damages are awarded when the injury is judged to be slight. Compensatory damages are awarded to repay of compensate the injured party for the injury incurred. Punitive damages are awarded when the injury is judged to have been committed
maliciously or in wanton disregard of the injured plaintiff’s interests.
CULTURAL COMPETENCY
A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in cross–cultural situations.
DAMAGES
Money awarded by a court to someone who has been injured (plaintiff) and that must be paid by the party responsible for the injury (defendant).
DAYS PER THOUSAND
A standard unit of measurement of utilization. Refers to an annualized use of the hospital or other institutional care. It is the number of hospital days that are used in a year for each thousand covered lives.
DBA
Defense Base Act of 1941
DEATH BENEFIT
The benefit payable to eligible dependent(s) of the worker (i.e., spouse, children) whose occupational disease or on-the- job injury has resulted in the worker’s death. This benefit may be payable at the rate of two-thirds of the deceased worker’s average weekly wage at the time of the accident, not to exceed the
maximum allowed under the law for all eligible dependents.
DECISION RULE
A logical statement of characteristics, conditions, or attributes (e.g., effectiveness,
worthiness, financial savings) that explain the appropriateness of making a specific decision or choice. For example, a healthcare executive concludes that a case
management intervention is of positive return on investment if it demonstrates cost savings.
DEDUCTIBLE
A specific amount of money the insured person must pay before the insurer’s payments for covered healthcare services begin under a medical insurance plan.
DEFENDANT
The person against whom an action is brought to court because of alleged responsibility for violating one or more of the plaintiff’s legally protected interests.
DELAY IN SERVICE
Used to identify delays in the delivery of needed services and to facilitate and expedite such services when necessary.
DELEGATION
The process whereby an organization permits another entity to perform functions
and assume responsibilities on behalf of the organization, while the organization retains final authority to provide oversight to the delegate.
DEMAND MANAGEMENT
Telephone triage and online health advice services to reduce members’ avoidable visits to health providers. This helps reduce unnecessary costs and contributes to better outcomes by helping members become more involved in their own care.
DENIAL
No authorization or certification is given for healthcare services because of the inability to provide justification of medical necessity or appropriateness of
treatment or length of stay. This can occur before, during, or after care provision.
DEPOSITION
The testimony of a witness taken upon interrogatories not in open court, but in pursuance of a commission to take testimony issued by a court, or under a
general law on the subject, and reduced to writing and duly authenticated, and intended to be used upon the trial of an action in court.
DHHS
Department of Health & Human Services
DIAGNOSIS-RELATED GROUP
(DRG)
A patient classification scheme that provides a means of relating the type of patient a hospital treats to the costs incurred by the hospital. DRGs demonstrate
groups of patients using similar resource consumption and length of stay. It also is known as a statistical system of classifying any inpatient stay into groups for the purposes of payment. DRGs may be primary or secondary; an outlier classification also exists. This is the form of reimbursement that the CMS uses to pay hospitals for Medicare and Medicaid recipients. Also used by a few states for all payers and by many private health plans (usually non-HMO) for contracting purposes.
DIAGNOSTIC AND
STATISTICAL MANUAL OF
MENTAL DISORDERS, 5TH
EDITION (DSM-5)
The most recent edition of the American Psychiatric Association’s manual that is used by clinicians and researchers to diagnose and classify mental disorders (American Psychiatric Association, 2013).
DICHOTOMOUS VARIABLE
A variable known to have only two characteristics or options when evaluated in a particular study or predictive modeling. For example, characteristics may be high or low, true or false, yes or no, present or absent.
DIFFUSION OF INNOVATION
The spread of new technologies, ideas, or ways of doing things in a particular culture. It is the process of communicating change for the purpose of increasing the rate of its adoption and acceptance.
DIRECT EXAMINATION
The first interrogation or examination of a witness, on the merits, by the party on whose behalf he/she is called.
DISABILITY CASE
MANAGEMENT
A process of managing occupational and nonoccupational diseases with the aim of returning the disabled employee to a productive work schedule and employment.
DISABILITY CASH BENEFIT
Cash paid by a disability benefits insurance agency to a worker out on disability who has otherwise lost wages due to an inability to work. The cash is paid over a specific period of time and is equivalent to a predetermined percentage of the worker’s weekly wages that have been lost due to inability to work. The amount is determined based on the average wages of the worker during a specific number of weeks (usually less than 10 weeks) most adjacent to the week during which the worker sustained the injury or illness. This benefit is also paid for a limited time period as stipulated by the disability insurance plan and based on state specific
laws.
DISABILITY INCOME
INSURANCE
A form of health insurance that provides periodic payments to replace income when an insured person is unable to work as a result of illness, injury, or disease.
DISABILITY MANAGEMENT
PROGRAM
A program that focuses on assisting workers who have suffered from occupational health conditions or job-related injuries return to work. It facilitates accommodations in the workplace to prevent impairment incidents of injured
workers from becoming disability circumstances. It also employs the services of health professionals such as disability management specialists and/or disability case managers who are responsible for training and establishing tools for disability management personnel, employers, and others involved in keeping workers healthy, motivated, and productive.
DISCHARGE OUTCOMES
(CRITERIA)
Clinical criteria to be met before or at the time of the client’s discharge. They are the expected/ projected outcomes of care that indicate a safe discharge.
DISCHARGE PLANNING
The process of assessing the client’s needs of care after discharge from a healthcare facility and ensuring that the necessary services are in place before discharge. This process ensures a client’s timely, appropriate, and safe discharge
to the next level of care or setting including appropriate use of resources necessary for ongoing care.
DISCHARGE SCREEN
Assessment of the client/support system’s discharge needs using a set of criteria that results in identifying clients who are to benefit from healthcare services
or resources post an episode of illness and/or to prevent need for acute care rehospitalization.
DISCHARGE STATUS
Disposition of the client at discharge (e.g., left against medical advice, expired, discharged home, transferred to a nursing home).
DISCLOSURE
Written authorization regarding the sharing of a client’s information with other parties or in proceedings such as a complaint of an alleged ethical violation, which otherwise parties have no business being aware of such information.
DISCOVERY
The process by which one party to a civil suit can find out about matters that are relevant to his/her case, including information about what evidence the other side has, what witnesses will be called upon, and so on.
DISENGAGEMENT
The closing of a case is a process of gradual or sudden withdrawal of services, as the situation indicates, on a planned basis.
DISENROLLMENT
The process of terminating healthcare insurance coverage for an enrollee/insured.
DISTRIBUTIVE JUSTICE
Deals with the moral basis for the dissemination of goods and evils, burdens and benefits, especially when making decisions regarding the allocation of healthcare resources.
DMAA
Disease Management Association of America
DME
Durable Medical Equipment
DNR
Do not resuscitate
DOD
Department of Defense
DOMESTIC CARRIER
An insurance company organized and headquartered in a given state is referred to in that state as a domestic carrier.
DUAL RELATIONSHIP
Dual relationships exist when a case manager has responsibilities toward a third
party other than the client (e.g., case manager/payor/client or case manager/ employer/client).
DURABLE MEDICAL
EQUIPMENT (DME)
Equipment needed by patients for self-care. Usually it must withstand repeated use, is used for a medical purpose, and is appropriate for use in the home setting.
EARLY RETURN-TO-WORK
When a worker who had suffered a job-related injury or illness resumes work before complete recovery and while still suffering some sort of a partial disability.
Usually the early return of the worker may involve the same job but with modified responsibilities or another job altogether.
EBP
Evidence-Based Practice
EDSS
Expanded Disability Status Scale
EF
Executive Function
EHR
Electronic health record
EFFECTIVENESS OF CARE
The extent to which care is provided correctly (i.e., to meet the client’s needs, improve quality of care, and resolve the client’s problems), given the current state of knowledge, and the desired outcome is achieved.
EFFICACY OF CARE
The potential, capacity or capability to produce the desired effect or outcome, as already shown, e.g. through scientific research (evidence-based) findings.
EFFICIENCY OF CARE
The extent to which care is provided to meet the desired effects/outcomes to improve quality of care and prevent the use of unnecessary resources.
ELECTRONIC MEDICAL
RECORD
A computerized medical and health record a healthcare organization (e.g., a hospital, rehabilitation facility, physician’s office or home care agency) uses as part of a health information system that allows documentation of important
information about a client’s status and care provision. It also allows storage, retrieval, and modification of records specific to the individual client the
organization is caring for. Other terms used to refer to EMIR are electronic patient record (EPR), electronic health record (EHR) and computer-based patient record (CPR).
EMOTIONAL INTELLIGENCE
The ability to sense, understand, and effectively apply the power and acumen of emotions as a source of energy, information, connection, and influence. It also
is the ability to motivate oneself and persist in the face of frustration; control impulse; regulate one’s mood; and keep distress from swamping the ability to think, empathize, and hope.
EMR
Electronic Medical Record
EMTALA
Emergency Medical Treatment and Active Labor Act
ENCOUNTER
An outpatient or ambulatory visit by a health plan member to a provider. It applies mainly to a physician’s office but may also apply to other types of encounters.
END-RESULT OUTCOMES
Outcomes that occur at the conclusion of an episode of care and indicate the achievement of target goals. For example, deciding to transition a client from the acute care to home setting after successful tolerance of oral antibiotics or transitioning a workers’ compensation client back to work after successful job
modification intervention(s).
ENROLLEE
An individual who subscribes for a health benefit plan provided by a public or private healthcare insurance organization.
EPISODE OF CARE
A client’s access to healthcare services or encounter with a healthcare provider. It is individual client-specific, time-limited and always has a beginning and end. The length of the client’s encounter with care varies based on the client’s health need(s), the type and intensity of the required services to effectively address the need, the care/practice setting where the client receives these services, and level of care. Time of the encounter may be measured in minutes (e.g., in a provider’s
clinic or office), hours (e.g., in the emergency department, ambulatory surgery center or a dialysis center), days (e.g., in a hospital setting) or weeks to months (e.g., in a skilled nursing or rehabilitation facility). A client suffering from an illness may require one or multiple episodes of care before the illness is resolved or client is considered stable.
EPO
Exclusive provider organization
EPR
Electronic patient record
ERGONOMICS (OR HUMAN
FACTORS)
The scientific discipline concerned with the understanding of interactions
among humans and other elements of a system. It is the profession that applies theory, principles, data and methods to environmental design (including work environments) in order to optimize human well-being and overall system performance.
ERGONOMIST
An individual who has (1) a mastery of ergonomics knowledge; (2) a command of
the methodologies used by ergonomists in applying that knowledge to the design
of a product, process, or environment; and (3) has applied his or her knowledge to
the analysis, design, test, and evaluation of products, processes, and environments.
ERISA
Employee Retirement Income Security Act.
EVALUATING OUTCOMES
The final step of the case management process, which is achieved by measuring the results and consequences of the case management services provided to clients and their support systems.
EVALUATION
The process, repeated at appropriate intervals, of determining and documenting
the case management plan’s effectiveness in reaching desired outcomes and goals.
EX PARTE
A judicial proceeding, order, injuction, and so on, taken or granted at the instance and for the benefit of one party only, and without notice to, or contestation by, any person adversely interested.
EXCHANGE VALUE
The tradability of a good or service and its associated price (i.e., what it is traded or exchanged for). Most often, exchange value is expressed using money (Smith, 2011).
EXCLUSIVE PROVIDER
ORGANIZATION (EPO)
A managed care plan that provides benefits only if care is rendered by providers within a specific network.
EXECUTIVE FUNCTION
Capacity of a person’s working memory which relies on one’s state of cognition, attention, aptitude, intellectual capacity, mental processes, ability to maintain focus, and ability to handle a breadth of ideas and facts (Cowen, Elliott, Scott Saults et al., 2005).
EXPERIENCE
A term used to describe the relationship, usually in a percentage or ratio, of premium to claims for a plan, coverage, or benefits for a stated period of time.
EXPERIENCE RATING
The process of determining the premium rate for a group risk, wholly or partially on the basis of that group’s experience.
EXPERIENCE REFUND
A provision in most group policies for the return of premium to the policy holder because of lower than anticipated claims.
EXPERT WITNESS
A person called to testify because of recognized competence in an area.
EXTERNAL BENCHMARKING
The act of comparing or evaluating the current performance of an organization or program against externally available data, standards, performance of competitors,
national databases, or ideal practices.
FAIR HEARING
One in which authority is executed fairly; that is consistent with the fundamental principles of justice embraced within the conception of due process of law.
FAM
Functional Assessment Measure
FCE
Functional capacity evaluation
FECA
Federal Employees Compensation Act.
FAST
Functional Assessment Staging
FFS
Fee for service
FEE SCHEDULE
A listing of fee allowances for specific procedures or services that a health plan will reimburse.
FEE-FOR-SERVICE (FFS)
Providers are paid for each service performed, as opposed to capitation. Fee schedules are an example of fee-for-service.
FIDELITY
The ethical principle that directs people to keep commitments or promises.
FIDUCIARY
Person in a special relationship of trust, confidence or responsibility in which one party occupies a superior relationship and assumes a duty to act in the
dependent’s best interest. This includes a trustee, guardian, counselor or institution, but it could also be a volunteer acting in this special relationship.
FIELD CASE MANAGEMENT
(FCM)
Also known as onsite case management. A form of care coordination and management whereby a case manager works with a client (worker) in person
rather than virtually via telephone or other electronic ways of communication. Field case managers usually visit the client, the client’s employer, work
environment, treating physician, and other involved parties and collaborate with them on the return of the client to work.
FIRST-LEVEL REVIEWS
Conducted while the client is in the hospital, care is reviewed for its appropriateness.
FOLLOWING-UP
The step of the case management process when case managers review, evaluate, monitor and reassess the client’s health condition, needs, ability for self-care, knowledge of health condition and case management plan of care, outcomes of the implemented treatments and interventions, and continued appropriateness of the plan of care.
FORMULARY
A list of prescription drugs that provide choices for effective medications from which providers may select, that are covered under a specific health plan.
FRAME OF REFERENCE
A set of ideas, evaluative criteria, rules, assumptions, or conditions a person uses to understand, perceive, and approach a situation or an issue. It is also the
viewpoint or context within which a person’s thinking about something seems to occur.
FRAUD
Knowingly and willfully executing, or attempting to execute a scheme or artifice to defraud any healthcare benefit program or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property
owned by, or under the custody or control of, any healthcare benefit program.
FUNCTIONAL CAPACITY
EVALUATION (FCE)
A systematic process of assessing an individual’s physical capacities and functional abilities. The FCE matches human performance levels to the demands of a specific job or work activity or occupation. It establishes the physical level of work an individual can perform. The FCE is useful in determining job placement, job accommodation or return to work after injury or illness. FCEs can provide objective information regarding functional work ability in the determination of occupational disability status.
FUNCTIONAL INDEPENDENCE
MEASURE (FIM)
An 18-item instrument with an
ordinal scale ranging from 1 (total assistance) to 7 (complete independence) that is used worldwide in the in-patient medical rehabilitation setting to measure a client’s ability to function with independence. The instrument allows healthcare
professionals to evaluate the amount of assistance required by a client to safely and effectively perform basic life functions. An FIM score is collected within 72 hours after a client’s admission to a rehabilitation unit, within
72 hours before discharge, and between 80 to 180 days after discharge. Items of the FIM address a client’s level of independence in the areas of eating; grooming; bathing; dressing (upper body), dressing (lower body); toileting; bladder management; bowel management; transferring (to go from one place to another) in a bed, chair, and/or wheelchair; transferring on and off a toilet; transferring into and out of a shower; locomotion (moving) for walking or in a wheelchair; and locomotion going up and down stairs. The FIM instrument is also used to assess a client’s cognitive abilities such as comprehension, expression, social interaction, problem solving, and memory.
FUNDING SYSTEMS
Individuals or agencies that provide financial resources to support the care of those who are poor, vulnerable, lack health insurance coverage or unable to
independently assume such responsibility. These may include charitable or religious organizations, and public or private agencies.
FUNERAL EXPENSE BENEFIT
Includes financial support for funeral expenses survivors of the diseased worker may incur. This benefit is payable to the deceased worker’s family or
dependent(s) up to the maximum allowed under the law at the time of the worker’s injury resulting in death.
GAG RULES
A clause in a provider’s contract that prevents physicians or other providers from revealing a full range of treatment options to clients or, in some instances, from revealing their own financial self-interest in keeping treatment costs down. These
rules have been banned by many states.
GATEKEEPER
A primary care physician (usually a family practitioner, internist, pediatrician, or nurse practitioner) to whom a plan member is assigned. Responsible for managing all referrals for specialty care and other covered services used by the member.
GLOBAL ASSESSMENT LENS
A multidimensional assessment that affords case managers the ability to be thorough and organized with respect to designing an individualized case
management plan of care for each client to meet the client’s unique situation. It includes an overview of the biophysical, psychological, sociological, and
spiritual dimensions care. It functions as a care approach for case management assessment, which provides a comprehensive overview of eight essential domains to be considered when contemplating a client’s needs and opportunities. These domains include physical health, behavioral health, functional capacity, client engagement and self-management, social determinants of health, health
information technology, data analytics and decision support, and transdisciplinary healthcare team.
GLOBAL FEE
A predetermined all-inclusive fee for a specific set of related services, treated as a single unit for billing or reimbursement purposes.
GOLD STANDARD
Also known as “ideal practice”; refers to the best available knowledge, evidence, or benchmark under reasonable or similar conditions.
GROUP MODEL HMO
The HMO contracts with a group of physicians for a set fee per client to provide many different health services in a central location. The group of physicians
determines the compensation of each individual physician, often sharing profits.
GUARDIAN
A person appointed by the court to be a substitute decision- maker for persons receiving services deemed to be incompetent of making informed decisions for themselves. The powers of a guardian are determined by a judge and may be limited to certain aspects of the person’s life.
