CCMC Glossary of Terms Flashcards

1
Q

AAPM&R

A

American Academy of Physical Medicine and Rehabilitation

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2
Q

ACCESS TO CARE

A

The ability and ease of clients to obtain healthcare when they need it.

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3
Q

ACCESSIBLE

A

A term used to denote building facilities that are barrier-free thus enabling all
members of society safe access, including persons with physical disabilities.

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4
Q

ACCOUNTABLE CARE
ORGANIZATION (ACO)

A

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.

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5
Q

ACCREDITATION

A

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.

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6
Q

ACTIONABLE TORT

A

A legal duty, imposed by statute or otherwise, owing by defendant to the one injured.

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7
Q

ACTIVE LISTENING

A

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.

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8
Q

ACTIVITIES OF DAILY LIVING
(ADLS)

A

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.

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9
Q

ACTIVITY LIMITATIONS

A

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.

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10
Q

ACTUAL VALUE

A

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.

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11
Q

ACTUARIAL STUDY

A

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.

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12
Q

ACTUARY

A

A trained insurance professional who specializes in determining policy rates, calculating premiums, and conducting statistical studies.

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13
Q

ACUITY

A

Complexity and severity of the client’s health/medical condition.

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14
Q

ACUTE CARE

A

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.

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15
Q

ADA

A

Americans with Disabilities Act of 1990

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16
Q

ADA AMENDMENTS ACT
(ADAAA)

A

Americans with Disabilities Act Amendments Act of 2008

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17
Q

ADL

A

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.

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18
Q

ADAPTIVE BEHAVIOR

A

The effectiveness and degree to which an individual meets standards of self-
sufficiency and social responsibility for his/her age-related cultural group.

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19
Q

ADHERENCE

A

“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).

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20
Q

ADHESIVE CONTRACT

A

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

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21
Q

ADJUSTED CLINICAL GROUP®
(ACG) SYSTEM:

A

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

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22
Q

ADJUSTER

A

A person who handles claims (also referred to as Claims Service Representative).

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23
Q

ADLS

A

See activities of daily living.

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24
Q

ADMINISTRATIVE LAW

A

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.

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25
Q

ADMINISTRATIVE SERVICES
ONLY (ASO)

A

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.

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26
Q

ADMISSION CERTIFICATION

A

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.

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27
Q

ADMISSION REVIEW

A

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.

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28
Q

ADVANCE DIRECTIVE

A

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.

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29
Q

ADVERSE EVENTS

A

Any untoward occurrences, which under most conditions are not natural consequences of the client’s disease process or treatment outcomes.

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30
Q

ADVOCACY

A

The act of recommending, pleading the cause of another; to speak or write in favor of.

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31
Q

ADVOCATE

A

A person or agency who speaks on behalf of others and promotes their cause.

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32
Q

AFFECT

A

The observable emotional condition of an individual at any given time.

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33
Q

AFFIDAVIT

A

A written statement of fact signed and sworn before a person authorized to administer an oath.

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34
Q

AGGREGATED DIAGNOSIS
GROUPS (ADGS)

A

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

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35
Q

AGREED MEDICAL
EXAMINATION

A

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.

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36
Q

AHA

A

American Heart Association

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37
Q

AHRQ

A

Agency for Healthcare Research and Quality

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38
Q

ALGORITHM

A

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.

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39
Q

ALTERNATE LEVEL OF CARE

A

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.

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40
Q

AMA

A

American Medical Association

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41
Q

AMBULATORY PAYMENT
CLASSIFICATION (APC)
SYSTEM

A

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.

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42
Q

ANA

A

American Nurses Association

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43
Q

ANCC

A

American Nurses Credentialing Center

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44
Q

ANCILLARY SERVICES

A

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.

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45
Q

APC

A

Ambulatory Payment Classification.

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46
Q

APPEAL (CARE PROVISION
RELATED)

A

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.

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47
Q

APPEAL (LEGAL IN NATURE)

A

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.

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48
Q

APPROPRIATENESS OF
SETTING

A

Used to determine if the level of care needed is being delivered in the most appropriate and cost-effective setting possible.

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49
Q

APPROVAL

A

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.

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50
Q

APPROVED CHARGE

A

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.

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51
Q

ASO

A

Administrative Services Only

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52
Q

ASSESSING

A

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

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53
Q

ASSIGNMENT OF BENEFITS

A

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.

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54
Q

ASSISTIVE DEVICE

A

Any tool that is designed, made, or adapted to assist a person to perform a particular task.

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55
Q

ASSISTIVE TECHNOLOGY

A

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.

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56
Q

ASSISTIVE TECHNOLOGY
SERVICES

A

Any service that directly assists an individual with a disability in the selection, acquisition, or use of an assistive technology device.

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57
Q

ASSUMPTION OF RISK

A

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.

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58
Q

ASSURANCE/INSURANCE

A

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.

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59
Q

AUTHORIZATION

A

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.

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60
Q

AUTONOMY

A

Agreement to respect another’s right to self-determine a course of action; support of independent decision making.

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61
Q

BAD FAITH

A

Generally involving actual or constructive fraud, or a design to mislead or deceive another.

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62
Q

BARRIER-FREE

A

A physical, manmade environment or arrangement of structures that is safe and accessible to persons with disabilities.

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63
Q

BARRIERS

A

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.

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64
Q

BAS

A

Burden Assessment Scale

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65
Q

BENCHMARKING

A

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.

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66
Q

BENEFICENCE

A

Compassion; taking positive action to help others; desire to do good; core principle of client advocacy.

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67
Q

BENEFICIARY

A

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.

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68
Q

BENEFIT PACKAGE

A

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.

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69
Q

BENEFIT PROGRAMS

A

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.

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70
Q

BENEFITS

A

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.

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71
Q

BEYOND (OUTSIDE)-THE-
WALLS CASE MANAGEMENT

A

Models where healthcare resources, services and case managers are based externally to an acute care/hospital setting, that is in the community.

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72
Q

BOARD-CERTIFIED CASE
MANAGER

A

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.

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73
Q

BODY OF KNOWLEDGE (BOK)

A

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

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74
Q

BOK

A

Body of Knowledge

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75
Q

BONA FIDE

A

Literally translated as “in good faith.”

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76
Q

BRAIN DISORDER

A

A loosely used term for a neurological disorder or syndrome indicating impairment or injury to brain tissue.

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77
Q

BRAIN INJURY

A

Any damage to tissues of the brain that leads to impairment of the function of the Central Nervous System.

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78
Q

BURDEN OF PROOF

A

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.

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79
Q

CAPACITY

A

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.

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80
Q

CAPITATION

A

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.

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81
Q

CAPTIVE

A

An insurance company formed by an employer to assume its workers’ compensation and other risks, and provide services.

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82
Q

CARE CONTINUUM ALLIANCE

A

Previously known as the Disease Management Association of America (DMAA).

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83
Q

CARE COORDINATION

A

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”.

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84
Q

CARE COORDINATION HUB

A

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.

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85
Q

CARE GUIDELINES

A

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.

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86
Q

CARE MANAGEMENT

A

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.

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87
Q

CARE SETTING

A

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).

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88
Q

CAREGIVER

A

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.

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89
Q

CARF

A

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.

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90
Q

CARPAL TUNNEL SYNDROME

A

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.”

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91
Q

CARRIER

A

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.

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92
Q

CARVE OUT

A

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.

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93
Q

CASE-BASED REVIEW

A

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.

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94
Q

CASE CLOSURE

A

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.

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95
Q

CASE CONFERENCE

A

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.

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96
Q

CASE LAW

A

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.

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97
Q

CASE MANAGEMENT

A

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.

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98
Q

CASE MANAGEMENT BODY
OF KNOWLEDGE (CMBOK)

A

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.

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99
Q

CASE MANAGEMENT
DEPARTMENT

A

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.

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100
Q

CASE MANAGEMENT MODEL

A

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.

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101
Q

CASE MANAGEMENT PLAN

A

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.

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102
Q

CASE MANAGEMENT PLAN
OF CARE

A

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.

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103
Q

CASE MANAGEMENT
PROCESS

A

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.

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104
Q

CASE MANAGEMENT
PROGRAM

A

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.

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105
Q

CASE MANAGER

A

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.

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106
Q

CASE MIX COMPLEXITY

A

An indication of the severity of illness, prognosis, treatment difficulty, need for intervention, or resource intensity of a group of clients.

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107
Q

CASE MIX GROUP (CMG)

A

Each CMG has a relative weight that determines the base payment rate for inpatient rehabilitation facilities under the Medicare system.

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108
Q

CASE MIX INDEX (CMI)

A

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.

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109
Q

CASE RATES

A

Rate of reimbursement that packages pricing for a certain category of services. Typically combines facility and professional practitioner fees for care and services.

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110
Q

CASE RESERVE

A

The dollar amount stated in a claim file which represents the estimate of the amount unpaid.

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111
Q

CASUALTY INSURANCE

A

A general class of insurance and workers’ compensation insurance.

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112
Q

CATASTROPHIC CASE

A

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.

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113
Q

CATASTROPHIC CASE
MANAGEMENT

A

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.

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114
Q

CATASTROPHIC ILLNESS

A

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.

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115
Q

CATASTROPHIC INJURY

A

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.

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116
Q

CCMC

A

Commission for Case Manager Certification

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117
Q

CERTIFIED NURSE LIFE CARE
PLANNER (CNLCP)

A

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.

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118
Q

CERTIFIED VOCATIONAL
EVALUATOR (CVE)

A

A professional specialized in vocational assessment and rehabilitation who has the
met the minimum requirements for nationally recognized voluntary certification.

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119
Q

CERTIFIED VOCATIONAL
REHABILITATION PROVIDER

A

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.

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120
Q

CHANGE MANAGEMENT

A

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.

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121
Q

CHRONIC CARE MODEL

A

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.

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122
Q

CLAIMANT

A

One who seeks a claim or one who asserts a right or demanding a legal proceeding.

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123
Q

CLAIMS ADJUSTER

A

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.

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124
Q

CLAIMS SERVICE
REPRESENTATIVE

A

A person who investigates losses and settles claims for an insurance carrier or the insured. A term preferred to adjuster.

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125
Q

CLIENT SOURCE

A

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.

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126
Q

CLIENT-RELATED OUTCOMES

A

Consequences or results of care activities, processes, or services that are directly related to the client’s condition, health status, and/or situation.

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127
Q

CLINICAL REVIEW CRITERIA

A

The written screens, decision rules, medical protocols, or guidelines used to evaluate medical necessity, appropriateness, and level of care.

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128
Q

CMAG

A

Case Management Adherence Guidelines

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129
Q

CMBOK

A

Case Management Body of Knowledge.

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130
Q

CMG

A

Case Mix Group

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131
Q

CMI

A

case mix index.

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132
Q

CMS

A

Centers for Medicare & Medicaid Services: Formerly known as the Health Care Financing Administration (HCFA).

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133
Q

CMSA

A

Case Management Society of America

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134
Q

COB

A

Coordination of Benefits

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135
Q

COBRA

A

Consolidated Omnibus Budget Reconciliation Act

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136
Q

CODING

A

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.

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137
Q

COGNITIVE REHABILITATION

A

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.

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138
Q

COINSURANCE

A

A type of cost sharing in which the insured person pays or shares part of the medical bill, usually according to a fixed percentage.

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139
Q

COLLABORATION

A

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.

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140
Q

COLLABORATIVE CARE

A

An evidence-based approach that involves the provision of mental health, behavioral health, and substance use services within a primary care setting.

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141
Q

COMMISSION ON
ACCREDITATION OF
REHABILITATION FACILITIES
(CARF)

A

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.

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142
Q

COMMON LAW

A

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.

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143
Q

COMMUNITY ALTERNATIVES

A

Agencies, outside an institutional setting, which provide care, support, and/or services to people with disabilities.

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144
Q

COMMUNITY ASSESSMENT
RISK SCREEN (CARS)

A

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

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145
Q

COMORBIDITY

A

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.

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146
Q

CONCURRENT REVIEW

A

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.

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147
Q

CONDITIONAL
REHABILITATION
PROFESSIONAL

A

A rehabilitation professional who has not yet met all of the requirements to be a qualified rehabilitation professional.

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148
Q

CONTEMPT OF COURT

A

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.

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149
Q

CONTINUED STAY REVIEW

A

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.

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150
Q

CONTINUOUS QUALITY
IMPROVEMENT (CQI)

A

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.

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151
Q

CONTINUUM OF CARE

A

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.

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152
Q

CONTRACTOR

A

A business entity that performs delegated functions on behalf of the organization.

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153
Q

CONTRACTUAL ETHICS

A

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.

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154
Q

COORDINATION OF BENEFITS
(COB)

A

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.

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155
Q

CORE THERAPIES

A

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.

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156
Q

CORF

A

Comprehensive Outpatient Rehabilitation Facility

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157
Q

COST-BENEFIT ANALYSIS

A

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).

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158
Q

CPR

A

Computer-based patient record

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159
Q

CPT

A

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.

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160
Q

CQI

A

Continuous Quality Improvement

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161
Q

CREDENTIALING

A

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.

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162
Q

CROSS EXAMINATION

A

The questioning of a witness during a trial or deposition by the party opposing those who originally asked him/her to testify.

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163
Q

CUSTODIAL CARE

A

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.

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164
Q

CULTURAL COMPETENCY

A

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.

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165
Q

DAMAGES

A

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).

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166
Q

DAYS PER THOUSAND

A

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.

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167
Q

DBA

A

Defense Base Act of 1941

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168
Q

DEATH BENEFIT

A

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.

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169
Q

DECISION RULE

A

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.

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170
Q

DEDUCTIBLE

A

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.

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171
Q

DEFENDANT

A

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.

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172
Q

DELAY IN SERVICE

A

Used to identify delays in the delivery of needed services and to facilitate and expedite such services when necessary.

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173
Q

DELEGATION

A

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.

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174
Q

DEMAND MANAGEMENT

A

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.

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175
Q

DENIAL

A

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.

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176
Q

DEPOSITION

A

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.

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177
Q

DHHS

A

Department of Health & Human Services

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178
Q

DIAGNOSIS-RELATED GROUP
(DRG)

A

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.

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179
Q

DIAGNOSTIC AND
STATISTICAL MANUAL OF
MENTAL DISORDERS, 5TH
EDITION (DSM-5)

A

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).

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180
Q

DICHOTOMOUS VARIABLE

A

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.

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181
Q

DIFFUSION OF INNOVATION

A

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.

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182
Q

DIRECT EXAMINATION

A

The first interrogation or examination of a witness, on the merits, by the party on whose behalf he/she is called.

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183
Q

DISABILITY CASE
MANAGEMENT

A

A process of managing occupational and nonoccupational diseases with the aim of returning the disabled employee to a productive work schedule and employment.

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184
Q

DISABILITY CASH BENEFIT

A

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.

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185
Q

DISABILITY INCOME
INSURANCE

A

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.

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186
Q

DISABILITY MANAGEMENT
PROGRAM

A

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.

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187
Q

DISCHARGE OUTCOMES
(CRITERIA)

A

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.

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188
Q

DISCHARGE PLANNING

A

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.

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189
Q

DISCHARGE SCREEN

A

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.

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190
Q

DISCHARGE STATUS

A

Disposition of the client at discharge (e.g., left against medical advice, expired, discharged home, transferred to a nursing home).

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191
Q

DISCLOSURE

A

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.

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192
Q

DISCOVERY

A

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.

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193
Q

DISENGAGEMENT

A

The closing of a case is a process of gradual or sudden withdrawal of services, as the situation indicates, on a planned basis.

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194
Q

DISENROLLMENT

A

The process of terminating healthcare insurance coverage for an enrollee/insured.

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195
Q

DISTRIBUTIVE JUSTICE

A

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.

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196
Q

DMAA

A

Disease Management Association of America

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197
Q

DME

A

Durable Medical Equipment

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198
Q

DNR

A

Do not resuscitate

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199
Q

DOD

A

Department of Defense

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200
Q

DOMESTIC CARRIER

A

An insurance company organized and headquartered in a given state is referred to in that state as a domestic carrier.

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201
Q

DUAL RELATIONSHIP

A

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).

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202
Q

DURABLE MEDICAL
EQUIPMENT (DME)

A

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.

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203
Q

EARLY RETURN-TO-WORK

A

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.

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204
Q

EBP

A

Evidence-Based Practice

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205
Q

EDSS

A

Expanded Disability Status Scale

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206
Q

EF

A

Executive Function

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207
Q

EHR

A

Electronic health record

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208
Q

EFFECTIVENESS OF CARE

A

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.

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209
Q

EFFICACY OF CARE

A

The potential, capacity or capability to produce the desired effect or outcome, as already shown, e.g. through scientific research (evidence-based) findings.

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210
Q

EFFICIENCY OF CARE

A

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.

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211
Q

ELECTRONIC MEDICAL
RECORD

A

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).

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212
Q

EMOTIONAL INTELLIGENCE

A

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.

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213
Q

EMR

A

Electronic Medical Record

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214
Q

EMTALA

A

Emergency Medical Treatment and Active Labor Act

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215
Q

ENCOUNTER

A

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.

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216
Q

END-RESULT OUTCOMES

A

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).

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217
Q

ENROLLEE

A

An individual who subscribes for a health benefit plan provided by a public or private healthcare insurance organization.

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218
Q

EPISODE OF CARE

A

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.

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219
Q

EPO

A

Exclusive provider organization

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220
Q

EPR

A

Electronic patient record

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221
Q

ERGONOMICS (OR HUMAN
FACTORS)

A

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.

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222
Q

ERGONOMIST

A

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.

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223
Q

ERISA

A

Employee Retirement Income Security Act.

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224
Q

EVALUATING OUTCOMES

A

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.

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225
Q

EVALUATION

A

The process, repeated at appropriate intervals, of determining and documenting
the case management plan’s effectiveness in reaching desired outcomes and goals.

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226
Q

EX PARTE

A

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.

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227
Q

EXCHANGE VALUE

A

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).

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228
Q

EXCLUSIVE PROVIDER
ORGANIZATION (EPO)

A

A managed care plan that provides benefits only if care is rendered by providers within a specific network.

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229
Q

EXECUTIVE FUNCTION

A

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).

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230
Q

EXPERIENCE

A

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.

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231
Q

EXPERIENCE RATING

A

The process of determining the premium rate for a group risk, wholly or partially on the basis of that group’s experience.

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232
Q

EXPERIENCE REFUND

A

A provision in most group policies for the return of premium to the policy holder because of lower than anticipated claims.

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233
Q

EXPERT WITNESS

A

A person called to testify because of recognized competence in an area.

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234
Q

EXTERNAL BENCHMARKING

A

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.

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235
Q

FAIR HEARING

A

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.

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236
Q

FAM

A

Functional Assessment Measure

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237
Q

FCE

A

Functional capacity evaluation

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238
Q

FECA

A

Federal Employees Compensation Act.

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239
Q

FAST

A

Functional Assessment Staging

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240
Q

FFS

A

Fee for service

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241
Q

FEE SCHEDULE

A

A listing of fee allowances for specific procedures or services that a health plan will reimburse.

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242
Q

FEE-FOR-SERVICE (FFS)

A

Providers are paid for each service performed, as opposed to capitation. Fee schedules are an example of fee-for-service.

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243
Q

FIDELITY

A

The ethical principle that directs people to keep commitments or promises.

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244
Q

FIDUCIARY

A

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.

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245
Q

FIELD CASE MANAGEMENT
(FCM)

A

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.

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246
Q

FIRST-LEVEL REVIEWS

A

Conducted while the client is in the hospital, care is reviewed for its appropriateness.

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247
Q

FOLLOWING-UP

A

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.

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248
Q

FORMULARY

A

A list of prescription drugs that provide choices for effective medications from which providers may select, that are covered under a specific health plan.

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249
Q

FRAME OF REFERENCE

A

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.

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250
Q

FRAUD

A

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.

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251
Q

FUNCTIONAL CAPACITY
EVALUATION (FCE)

A

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.

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252
Q

FUNCTIONAL INDEPENDENCE
MEASURE (FIM)

A

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.

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253
Q

FUNDING SYSTEMS

A

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.

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254
Q

FUNERAL EXPENSE BENEFIT

A

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.

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255
Q

GAG RULES

A

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.

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256
Q

GATEKEEPER

A

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.

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257
Q

GLOBAL ASSESSMENT LENS

A

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.

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258
Q

GLOBAL FEE

A

A predetermined all-inclusive fee for a specific set of related services, treated as a single unit for billing or reimbursement purposes.

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259
Q

GOLD STANDARD

A

Also known as “ideal practice”; refers to the best available knowledge, evidence, or benchmark under reasonable or similar conditions.

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260
Q

GROUP MODEL HMO

A

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.

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261
Q

GUARDIAN

A

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.

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262
Q

HABILITATION

A

The process by which a person with developmental disabilities is assisted in acquiring and maintaining life skills to: (1) cope more effectively with personal
and developmental demands; and (2) to increase the level of physical, mental, vocational and social ability through services. Persons with developmental
disabilities include anyone whose development has been delayed, interrupted or stopped/fixed by injury or disease after an initial period of normal development,
as well as those with congenital condition.

263
Q

HANDICAPPED

A

Refers to the disadvantage of an individual with a physical or mental impairment HANDOFFresulting in a handicap.

264
Q

HANDOFF

A

The act or an instance of passing something or the control of it from one person or agency to another. In healthcare context, handoff is passing of accountability and responsibility for a client’s care from one clinician to another within a care
setting or across care settings. This act is especially necessary during a transitions of care situation.

265
Q

HCC

A

Hierarchal conditions category

266
Q

HCFA

A

Health Care Financing Administration.

267
Q

HEALTH AND HUMAN
SERVICES CONTINUUM

A

Principal Term: The continuum of care that matches ongoing needs of case management clients and their support systems with the appropriate level and type of health, medical, financial, legal, psychosocial, behavioral and sprirtual care and services across one or more care settings. The continuum includes multiple
levels that vary in complexity and intensity of healthcare services and resources including individual care providers and organizations or agencies.

268
Q

HEALTH BENEFIT PLAN

A

Any written health insurance plan that pays for specific healthcare services on behalf of covered enrollees.

269
Q

HEALTH INSURANCE
PORTABILITY AND
ACCOUNTABILITY ACT
(HIPPA)

A

A civil rights legislation that governs the portability and continuity of health
insurance by protecting individuals against laws regarding preexisting health
conditions and other restrictions especially when changing jobs or insurance carriers and plans.

270
Q

HEALTH INSURANCE
PORTABILITY
AND ACCOUNTABILITY ACT’S
PRIVACY RULE

A

HIPAA’s Privacy Rule was initially published in 2000 as a national law that ensures clients’ medical information is kept confidential. The Rule offered clients greater
rights for protection of individually identifiable health information and files and
demands that all healthcare providers maintain strict confidentiality and privacy

271
Q

HEALTH MAINTENANCE
ORGANIZATION (HMO)

A

An organization that provides or arranges for coverage of designated health services needed by plan members for a fixed prepaid premium. There are four basic models of HMOs: group model, individual practice association (IPA), network model, and staff model. Under the Federal HMO Act an organization
must possess the following to call itself an HMO: (1) an organized system for providing healthcare in a geographical area, (2) an agreed-on set of basic and
supplemental health maintenance and treatment services, and (3) a voluntarily
enrolled group of people.

272
Q

HEALTH RISK ASSESSMENT
(HRA)

A

An assessment of a client conducted to identify the presence of risk and determine how such risk may influence health-seeking behavior (e.g., access to healthcare services). This assessment may cover various aspects of a client’s
condition – e.g., level of physical activity and exercise; nutritional status; general health, safety, social, and environmental wellness; emotional awareness; mental, intellectual, and occupational wellness; and culture including values, spirituality, and beliefs.

273
Q

HEALTHCARE CONTINUUM

A

Care settings that vary across a continuum based on levels of care that are also characterized by complexity and intensity of resources and services

274
Q

HEALTHCARE DELIVERY
SYSTEM

A

A comprehensive model or structure used in the delivery of healthcare services to individuals–for example, integrated delivery system (IDS).

275
Q

HEALTHCARE HOME

A

The usual setting or level of care the client/support system selects to use on a routine basis to receive healthcare services such as a large or small medical group,
a single practitioner, a community health center, or a hospital outpatient clinic. This is the central point for primary clinician caring for the client to coordinate necessary care and services based on the client’s needs and preferences and
among various care settings and providers.

276
Q

HEALTHCARE PROXY

A

A legal document that directs the healthcare provider/agency in whom to contact for approval/consent of treatment decisions or options whenever the client is no longer deemed competent to decide for self.

277
Q

HEALTHCARE TRILOGY

A

The quality, cost, and outcomes aspects of healthcare delivery. This term is attributed to the works of Donabedian.

278
Q

HEARING

A

A live proceeding done before a formal body with decision making authority for the purpose
of presenting evidence about an issue where concerned opposing parties are given the opportunity to share their side of the issue.
This procedure ultimately allows the decision-making body to determine the outcome and share its conclusions with the opposing parties.

279
Q

HEARSAY

A

Evidence not proceeding from the personal knowledge of the witness, but from the mere repetition of what has been heard from others.

280
Q

HEDIS

A

Healthcare Effectiveness Data and Information Set

281
Q

HHA

A

Home health aide

282
Q

HHRG

A

Home Health Resource Group

283
Q

ICD-9-CM

A

International Classification of Diseases, Ninth Revision, Clinical Modification

284
Q

ICT

A

Interdisciplinary care team

285
Q

IDS

A

Integrated delivery system

286
Q

IHI

A

Institute for Healthcare Improvement

287
Q

IM

A

Important Message from Medicare

288
Q

IMPAIRMENT

A

A general term indicating injury, deficiency or lessening of function. Impairment is a condition that is medically determined and relates to the loss or abnormality of psychological, physiological, or anatomical structure or function. Impairments are disturbances at the level of the organ and include defects or loss of limb, organ or other body structure or mental function, e.g. amputation, paralysis, mental retardation, psychiatric disturbances as assessed by a physical.

289
Q

IMPEACH

A

In the law of evidence, it is to call in question the veracity of a witness, by means of evidence adduced for that purpose.

290
Q

IMPLEMENTATION

A

The process of executing specific case management activities and/or interventions that will lead to accomplishing the goals set forth in the case management plan.

291
Q

IMPLEMENTING

A

The step in the case management process during which case managers execute
specific case management activities and/or interventions to accomplish goals set forth in the case management plan of care and during the planning step.

292
Q

IMPORTANT MESSAGE FROM
MEDICARE (IM)

A

A notice of discharge from the acute care setting that hospitals are required to deliver to all Medicare beneficiaries (original Medicare beneficiaries and Medicare Advantage plan enrollees) who are hospitalized, informing them of their hospital
discharge appeal rights.

293
Q

INCENTIVE

A

A sum of money paid at the end of the year to healthcare providers by an insurance/managed care organization as a reward for the provision of quality and cost-effective care.

294
Q

INCLUSIVE EDUCATION

A

An educational model in which students with disabilities receive their education in a general educational setting with collaboration between general and special education teachers. Implementation may be through the total reorganization and
redefinition of general and special education roles, or as one option in a continuum of available services.

295
Q

INDEMNITY

A

Security against possible loss or damages. Reimbursement for loss that is paid in a predetermined amount in the event of covered loss.

296
Q

INDEMNITY BENEFITS

A

Benefits in the form of payments rather than services. In most cases after the provider has billed the client, the insured person is reimbursed by the company.

297
Q

INDEPENDENT CASE
MANAGEMENT

A

Also known as private case management or external case management, it entails the provision of case management services by case managers who are either self- employed or are salaried employees in a privately owned case management firm.

298
Q

INDEPENDENT LIVING

A

A service delivery concept that encourages the maintenance of control over one’s life based on the choice of acceptable options that minimize reliance on others
performing everyday activities.

299
Q

INDEPENDENT MEDICAL
EXAMINATION/EVALUATION

A

An examination or evaluation that is completed by a healthcare professional (e.g., physician, physical therapist, psychologist) who has not been involved in the care of a worker who has sustained a work-related injury or illness. An employer or an insurance provider may request such an examination for a worker who is out of work on disability. The purpose of this examination is to determine the cause, extent, and medical treatment of a work-related or other injury where liability is
at issue. It also assists in determining whether a worker has reached the maximum
benefit from treatment and whether any permanent impairment remains after treatment.

300
Q

INDICATOR

A

A measure or metric that can be used to monitor and assess quality and outcomes of important aspects of care or services. It measures the performance of functions,
processes, and outcomes of an organization.

301
Q

INDIVIDUAL PRACTICE
ASSOCIATION (IPA)

A

A health maintenance organization (HMO) model of insurance that contracts with a private practice physician or healthcare association to provide healthcare services in return for a negotiated fee. The IPA then contracts with physicians who continue in their existing individual or group practice.

302
Q

INDIVIDUAL WRITTEN
REHABILITATION PROGRAM

A

(IWRP) An official document that clearly describes the individualized services that will enable a person with a disability to obtain and maintain suitable employment and/or to maximize independence in daily living. The formality of this document
allows the vocational rehabilitation professional (e.g., counselor) and the person
with the disability to translate findings of a vocational evaluation into specific
rehabilitation goals and objectives. This document also includes the medical, social,
psychological, educational, vocational, counseling, and employment services needed to accomplish the goal of the rehabilitation plan.

303
Q

INDIVIDUALIZED PLAN FOR
EMPLOYMENT (IPE)

A

A written plan that outlines an individual’s vocational goal and the services to be provided to reach the goal. It formalizes the planning process through which the vocational goal, service delivery, and time frames for service delivery are determined. It also identifies the individual’s employment objective, consistent
with his/her unique strengths, resources, priorities, concerns, abilities, and capabilities, while providing a plan for monitoring progress toward achievement of
the goal.

304
Q

INFORMED CONSENT

A

Consent given by a client, next of kin, legal guardian, or designated person for a kind of intervention, treatment, or service after the provision of sufficient information by the provider. A decision based on knowledge of the advantages and disadvantages and implications of choosing a particular course of action.

305
Q

INPATIENT REHABILITATION
FACILITIES PATIENT
ASSESSMENT INSTRUMENT
(IRF-PAI)

A

A diagnostic used to classify patients into distinct groups based on clinical characteristics and expected resource needs. The PAI determines the Case Mix
Group (CMG) classification.

306
Q

INSTRUMENTAL ACTIVITIES
OF DAILY LIVING (IADLS)

A

A set of skills necessary for an individual to maintain independent living. These skills require cognitive, emotional, and physical capacity for successful
performance. They include the ability to use a telephone, shop for groceries, handle finances, perform housekeeping tasks, prepare meals, do laundry, take
medications, and transportation use. These daily life functions are necessary for maintaining an individual’s independent living. They also are affected by
the presence of disease, injury, or developmental disability. Similar to ADLs, assessment of an individual’s ability to perform these skills is important for
determining an individual’s ability, independence, disability, or limitations. This assessment determines whether an individual needs personal care services and the benefit coverage required.

307
Q

INSURED

A

The person, organization, or other entity who purchases insurance.

308
Q

INSURER

A

The insurance company or any other organization that assumes the risk and provides the policy to the insured.

309
Q

INTAKE

A

The decision a case manager makes about the provision of case management services to a client or client’s support system.

310
Q

INTEGRATED BEHAVIORAL
HEALTH

A

The care a patient experiences as a result of a team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical
illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization

311
Q

INTEGRATED CARE

A

A concept that brings together inputs, delivery, management and organization of services related to diagnosis, treatment, care, rehabilitation, and health promotion. Integration is a means to improve services in relation to access, quality, user
satisfaction, and efficiency

312
Q

INTEGRATED CASE
MANAGEMENT

A

A process by which a single case manager assists clients/support systems with all barriers to health, including those related to physical illnesses or mental health and substance use disorders (mental conditions). Handoffs among case managers
and care providers are minimized, and total health outcomes for clients are the
responsibility of each individual case manager

313
Q

INTEGRATED DELIVERY
SYSTEM (IDS)

A

A single organization or group of affiliated organizations that provides a wide spectrum of ambulatory and tertiary care and services. Care may also be provided across various settings of the healthcare continuum.

314
Q

INTENSITY OF SERVICE (IS)

A

An acuity of illness criteria based on the evaluation/treatment plan, interventions, and anticipated outcomes.

315
Q

INTERACTIVE VOICE
RESPONSE (IVR)

A

A type of communication technology that allows individuals to interact with others (e.g., representatives of a company such as a health insurance plan) through the technology rather than actual people and via a telephone keypad or voice recognition system. During the automated interaction, individuals are able
to address their own inquiries by following the automated IVR dialogue. The IVR technology employs prerecorded audio to further direct users on how to proceed usually following a menu of choices. Interactions proceed in a simple way from
general options at first to more specific options later on in the dialog.

316
Q

INTER-DISCIPLINARY

A

Collaboration occurs among different disciplines that address inter-connected aspects of the client’s defined health problem or needs. The members of the team bring their own theories and frameworks to bear on the problem and connections
are sought among the disciplines to improve client outcomes.

317
Q

INTERDISCIPLINARY CARE
TEAM (ICT)

A

A team of healthcare professionals and paraprofessionals from different
disciplines or departments within an organization who are involved in the care of a client/support system, share common care goals, and who have responsibility for complementary tasks, interventions, and/or treatments necessary to meet
the client’s goals. The team is interdependent and participates in ongoing communication among the team members and with the client/support system to
ensure the various aspects of the client’s needs and wishes are addressed.

318
Q

INTERMEDIATE OUTCOME

A

A desired outcome that is met during a client’s hospital stay. Itis a milestone in the care of a client or a trigger point for advancement in the plan of care.

319
Q

INTERNAL BENCHMARKING

A

The act of comparing or evaluating the current performance of an organization or program against its past performance and improvement standard(s) or target(s).

320
Q

INTERNATIONAL
CLASSIFICATION OF
DISEASES,NINTH REVISION,
CLINICAL MODIFICATION
(ICD- 9-CM)

A

A text formulated to standardize diagnoses. It is used for coding medical records in preparation for reimbursement, particularly in the inpatient care setting.

321
Q

INTERQUAL CRITERIA

A

Nationally recognized standards that describe when and how an individual client with a specific health condition is expected to progress through the continuum
of healthcare and human services. They are developed applying a rigorous content process that ensures the criteria offer the best possible support for appropriateness of care and related clinical decision making. The criteria are of three types (acute care/hospitals, behavioral health, and payor) and focus on
care planning, level of care, clinical evidence summaries, and retrospective monitoring.

322
Q

INTERROGATORIES

A

A set or series of written questions composed for the purpose of being propounded to a party in equity, a garnishee, or a witness whose testimony is
taken in a deposition.

323
Q

INTERVENTION

A

Planned strategies and activities that modify a maladaptive behavior or state of being and facilitate growth and change. Intervention is analogous to the
medical term TREATMENT. Intervention may include activities such as advocacy,
psychotherapy, or speech language therapy.

324
Q

IOM

A

Institute of Medicine

325
Q

IPA

A

Individual Practice Association

326
Q

IPE

A

Individual plan for employment

327
Q

IRF

A

Inpatient rehabilitation facility

328
Q

IRF-PAI

A

See Inpatient Rehabilitation Facilities Patient Assessment Instrument

329
Q

IS

A

Intensity of service

330
Q

IT

A

Information technology

331
Q

IV

A

Intravenous

332
Q

JCAHO

A

Joint Commission on Accreditation of Health Care Organizations

333
Q

JCI

A

Joint Commission International

334
Q

JOB ACCOMMODATION

A

A reasonable adjustment to a job or work environment that makes it possible for an individual with a disability to perform job duties. Determining whether to provide accommodations involves considering the required job tasks, the functional limitations of the person doing the job, the level of hardship to the employer, and other issues.

335
Q

JOB ANALYSIS

A

A process to identify and determine in detail the particular job duties and requirements and the relative importance of these duties for a given job. Job analysis focuses on the specific job and not the person who occupies it at the time of analysis. It is conducted for purposes of a disabled worker’s work accommodation or training, identification of required skills, competencies and qualifications, and legal defense.

336
Q

JOB BANK SERVICE

A

A computerized system developed by the Department of Labor that maintains an up-to-date listing of job vacancies available through the State Employment Service.

337
Q

JOB CLUB

A

An organization of individuals who are seeking work, who join together to share information about employers, interviewing strategies, job seeking skills, and work opportunities.

338
Q

JURISDICTION

A

An entity possessing official power to make legal decisions and judgments based upon the authority granted to it. Usually the entity represents a legal body that administers justice within a defined area of responsibility.

339
Q

KNOWLEDGE DOMAIN

A

Principal Term: A cluster of health and human services or related topics (information) grouped together based on a common theme to form a high-level/abstract concept that is considered to be essential for effective and competent performance of case managers; for example, case management Principles of Practice or Healthcare Reimbursement.

340
Q

KNOWLEDGE FRAMEWORK

A

What case managers need to know to effectively care for clients and their support systems. It includes a nine-step case management process and seven essential knowledge domains applicable in any care or practice setting and for the various healthcare professionals who assume the case manager’s role.

341
Q

KPSS

A

Karnofsky Performance Status Scale

342
Q

LEGAL RESERVE

A

The minimum reserve which a company must keep to meet future claims and obligations as they are calculated under the state insurance code.

343
Q

LENGTH OF STAY (LOS)

A

The number of days that a health plan member/client stays in an inpatient facility, home health, or hospice.

344
Q

LETTER OF INSTRUCTION

A

A written statement expressing concern with a board certified case manager’s actions in regard to the CCMC’s Code of Professional Conduct. The concern is not significant enough to warrant a more serious action or sanction; however issuing of the letter of instruction serves as a reminder for the case manager to adhere to the Code in his/her case management practice.

345
Q

LEVEL OF CARE

A

Principle Term: The intensity and effort of health and human services and care activities required to diagnose, treat, preserve or maintain a client’s health. Level of care may vary from least to most complex, least to most intense, or prevention
and wellness to acute care and services.

346
Q

LEVELS OF SERVICE

A

Based on the client’s condition and the needed level of care, used to identify and verify that the client is receiving care at the appropriate level.

347
Q

LHWCA

A

Longshore and Harbor Workers’ Compensation Act

348
Q

LIABILITY

A

Legal responsibility for failure to act appropriately or for actions that do not meet the standards of care, inflicting harm on another person.

349
Q

LICENSE

A

A permit to practice medicine or a health profession that is: issued by a state or jurisdiction in the United States; and required for the performance of job functions.

350
Q

LIEN

A

A charge or security or encumbrance upon property.

351
Q

LIFE CARE PLAN

A

A dynamic document based on published standards of practice, comprehensive assessment, research, and data analysis, which provides an organized, concise plan for current and future needs [of the client and support system], with
associated costs, for individuals who have experienced catastrophic injury or have
chronic health care needs

352
Q

LIFE CARE PLANNING

A

A holistic, person-centered approach to the management of healthcare and services of a person with complex, catastrophic, or life-altering condition or disability with the ultimate goal to promote and maintain the person’s good
health, safety, well-being, and quality of life. It applies a consistent methodology
for analyzing all of the actual present and potential future needs and their associated expenses dictated by the onset of a catastrophic disability through to the end of life expectancy.

353
Q

LITERACY

A

Ability to read and write

354
Q

LITIGATION

A

A contest in a court for the purpose of enforcing a right, particularly when inflicting harm on another person.

355
Q

LIVING WILL

A

A legal document that directs the healthcare team/provider in holding or withdrawing life support measures. It is usually prepared by the client while he or she is competent, indicating the client’s wishes.

356
Q

LOBBYING

A

A form of advocacy whereby an individual or group attempts to influence decisions made by those in positions of authority/power such as politicians, legislatures, regulators, government officials, agency executives, advocacy groups or others.

357
Q

LOBBYIST

A

An individual, such as an advocate, who attempts to influence the decisions of those in positions of authority with the primary goal of promoting a special cause or agenda.

358
Q

LONG-TERM DISABILITY
INCOME INSURANCE

A

Insurance issued to an employee, group, or individual to provide a reasonable replacement of a portion of an employee’s earned income lost through a serious
prolonged illness during the normal work career.

359
Q

LORS

A

Level of Rehabilitation Scale

360
Q

LOS

A

Length Of Stay

361
Q

LOSS CONTROL

A

Efforts by the insurer and the insured to prevent accidents and reduce loss through the maintenance and updating of health and safety procedures.

362
Q

LOSS EXPENSE ALLOCATED

A

That part of expense paid by an insurance company in settling a particular claim, such as legal fees, by excluding the payments to the claimant.

363
Q

LOSS RATIO

A

The percent relationship which losses bear to premiums for a given period.

364
Q

LOSS RESERVE

A

The dollar amount designated as the estimated cost of an accident at the time the first notice is received.

365
Q

LOST WAGES

A

The income a worker does not earn due to an inability to return to work as a result of a work-related disability or extended absence.

366
Q

LOST WAGES BENEFIT

A

Often in cases of lost wages due to a job-related disability and extended absence from work, the disabled worker is entitled to lost wages benefits. The amount of lost wages paid as a benefit to the worker while out on disability is determined based on state workers’ compensation and disability laws and the worker’s weekly income at the time the work-related injury or illness occurred. Other terms used to
describe this benefit include cash benefit, disability cash benefit, and lost income benefit.

367
Q

MALPRACTICE

A

Improper care or treatment by a healthcare professional. A wrongful conduct.

368
Q

MANAGED CARE

A

A system of healthcare delivery that aims to provide a generalized structure and focus when managing the use, access, cost, quality, and effectiveness of
healthcare services. Links the client to provider services.

369
Q

MANAGED COMPETITION

A

A state of healthcare delivery in which a large number of consumers choose among
health plans that offer similar benefits. In theory, competition would be based on cost and quality and ideally would limit high prices and improve quality of care.

370
Q

MANAGEMENT SERVICE
ORGANIZATION

A

A management entity owned by a hospital, physician organization, or third party. It contracts with payers and hospitals/physicians to provide certain healthcare management services such as negotiating fee schedules and handling administrative functions, including utilization management, billing, and collections.

371
Q

MANDATORY OUTCOMES
REPORTS

A

Reports that consist of outcomes measures required by accreditation agencies such as The Joint Commission (TJC) or the National Committee for Quality
Assurance (NCQA) and regulatory bodies such as the Centers for Medicare & Medicaid Services (CMS) or the Department of Health & Human Services (DHHS). They often are publicly reported. Examples are core measures submitted to CMS,
or HEDIS measures submitted to NCQA.

372
Q

MAP

A

Multidisciplinary action plan

373
Q

MAXIMUM MEDICAL
IMPROVEMENT (MMI)

A

The point at which the health or medical condition of a worker who has sustained a work-related injury or illness has stabilized and further improvements are considered unlikely despite continued care and treatment. The treating physician at this time usually explains that no other reasonable treatment can be done to help the worker improve.

374
Q

MCO

A

Managed Care Organization

375
Q

MDS

A

Minimum Data Set

376
Q

MEDICAL DISABILITY
ADVISOR

A

A reference that provides disability duration guidelines, mostly used as a source of accurate data for estimating the potential duration of a disability and therefore the timeframes of return to work for certain work-related diseases and injuries.

377
Q

MEDICAL DURABLE POWER
OF ATTORNEY

A

A legal document that names a surrogate decision maker in the event that the patient becomes unable to make his or her own healthcare decisions.

378
Q

MEDICAL HEALTH

A

Healthcare services provided to manage physiologic and functional health conditions that relate to a person’s biologic systems and organs.

379
Q

MEDICAL HOME

A

A health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries,
information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want
it in a culturally and linguistically appropriate manner.

380
Q

MEDICAL LOSS RATIO

A

The ratio of healthcare costs to revenue received, calculated as total medical expense divided by total revenue.

381
Q

MEDICAL NECESSITY ON
ADMISSION

A

A type of review used to determine that the hospital admission is appropriate,
clinically necessary, justified, and reimbursable.

382
Q

MEDICAL OUTCOMES STUDY
SHORT FORM 36 (SF-36)

A

A research instrument used to measure an individual’s perception of his/her own
health status and quality of life.

383
Q

MEDICALLY NECESSARY

A

A term used to describe the supplies and services provided to diagnose and treat a medical condition in accordance with nationally recognized standards.

384
Q

MEDICARE

A

A nationwide federally administered health insurance program that covers the cost of hospitalization, medical care, and some related services for eligible
persons. Medicare has two parts. Part A covers inpatient hospital costs (currently reimbursed prospectively using the DRG system). Medicare pays for
pharmaceuticals provided in hospitals but not for those provided in outpatient
settings. Also called Supplementary Medical Insurance Program. Part B covers
outpatient costs for Medicare clients (currently reimbursed retrospectively).

385
Q

MEDICARE SECONDARY
PAYER

A

A term generally used when the Medicare program does not have primary payment responsibility – that is, when another payor/insurance company has the responsibility for paying before Medicare.

386
Q

MEDICATION
RECONCILIATION

A

The process of examining and monitoring all medications taken by a client to determine their compatibility, necessity and safety in order to reduce the number of adverse drug affects and promote client’s adherence to the medication regimen.

387
Q

MENTORING

A

A formal or informal relationship between two people, a senior mentor and a junior protégé.
The relationship aims to facilitate the professional development and advancement of the protégé. During this process the expert advises, guides, and further
develops the protégé to facilitate meeting the protégé’s career goals.

388
Q

METABOLIC EQUIVALENT OF
TASK (MET)

A

A physiologic measure that expresses the energy cost of physical activities and is defined as the ratio of metabolic rate (or rate of energy consumption)
during a specific physical activity to a reference metabolic rate (rate of energy consumption during rest).

389
Q

MILLIMAN CARE GUIDELINES

A

Nationally recognized guidelines that offer integrated, diagnosis-specific references, footnotes, and abstracts. Clinicians and payors use them as tools to
help drive higher- quality of care especially in the use of medical resources. The guidelines focus on reducing variances from best-practice care delivery, provide
tools that support discharge planning and care transitions, assist clinicians in the appropriate documentation of clients’ levels of care, and support the delivery of client-centered care.

390
Q

MINIMUM DATA SET

A

The assessment tool used in skilled nursing facility settings to place patients into Resource Utilization Groups (RUGs), which determines the facility’s reimbursement rate.

391
Q

MLR

A

Medical loss ratio

392
Q

MMSE

A

Mini-Mental State Examination

393
Q

MONITORING

A

The ongoing process of gathering sufficient information from all relevant sources and its documentation regarding the case management plan and its activities and/or services to enable the case manager to determine the plan’s effectiveness.

394
Q

MOTIVATIONAL INTERVIEWING

A

An effective communication technique applied to gather important information and obtain insights into a client’s situation and health condition, focusing on the clinical, social, financial, mental, behavioral, and emotional aspects of the client’s status. It is a style of communication that is supportive, empathic, and counseling- like that helps clients/support systems move more easily toward a course of successful and desirable change.

395
Q

MSP

A

Medical Secondary Payor

396
Q

MULTIDISCIPLINARY ACTION
PLAN (MAP)

A

Also known as a 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.

397
Q

NACCM

A

National Academy of Certified Care Managers

398
Q

NCQA

A

National Committee for Quality Assurance

399
Q

NASW

A

National Association of Social Workers

400
Q

NATIONAL QUALITY
MEASURES CLEARINGHOUSE

A

Also referred to as NQMC. It is a public resource for evidence-based quality measures and measure sets. The U.S. Department of Health & Human Services (HHS) sponsors this resource of quality measures through its affiliate, the Agency
for Healthcare Research and Quality (AHRQ). NQMC provides the public with an inventory of the measures that are currently being used by the HHS for quality
measurement, improvement, and reporting

401
Q

NEGATIVE PREDICTIVE
VALUE (NPV)

A

The proportion of clients (also referred to as enrollees or members in a health insurance plan) who are predicted to experience low-cost services that turn out to be truly low cost.

402
Q

NEGLIGENCE

A

Failure to act as a reasonable person. Behavior is contrary to that of any ordinary person facing similar circumstances.

403
Q

NETWORK MODEL HMO

A

The fastest growing form of managed care, this plan contracts with a variety of groups of physicians and other providers in a network of care with organized referral patterns. Networks allow providers to practice outside the HMO.

404
Q

NEVER EVENTS

A

Healthcare events that are undesirable, considered rare but devastating (resulting in death or serious disability) for the client when they occur, and are classified as medical errors. They are preventable in nature and healthcare organizations and
providers are pressured to eliminate or prevent their occurence. Never events
fall into six categories according to the National Quality Forum (NQF): surgical such as wrong site surgery, product of device such as contaminated drug, patient
protection such as suicide, care management event such as wrong dose drug, environmental such as electric shock, and criminal such as sexual assault.

405
Q

NO EXPARTE
COMMUNICATION

A

Case managers under no circumstances can discuss the medical treatment plans with the treating physicians separate from the workers who suffered a work- related injury or illness. This extends not only to verbal but also to any written communications that the case manager may send to the treating physician.

406
Q

NONADHERENCE

A

A person’s behavior that does not correspond with agreed upon recommendations from a healthcare provider or demonstrates inability or
indifference about following the recommendations (e.g., health regimen), such as continued tobacco use despite the instruction to give up smoking.

407
Q

NONMALEFICENCE

A

Refraining from doing harm to others; that is, emphasizing quality care outcomes.

408
Q

NPP

A

National Priorities Partnership

409
Q

NQF

A

National Quality Forum

410
Q

NURSE LICENSURE COMPACT
(NLC)

A

A legal agreement that allows nurses, based on enacted laws, to have one multistate license, allowing them the ability to practice in both their home and
other states that have agreed to belong to the compact. States that belong to the compact recognize the nurse’s licensure from the state of residence and eliminate the requirement of the nurse needing licensure in each of the states she/he chooses to work in as long as the state belongs to the compact.

411
Q

NURSING CASE
MANAGEMENT

A

A process model using the components of case management in the delivery
aspects of nursing care. In nursing case management delivery systems, the role
of the case manager is assumed by a registered professional nurse.

412
Q

OASIS

A

Outcome and Assessment Information Set: A prospective nursing assessment instrument completed by home health agencies at the time the patient is entered for home health services. Scoring determines the Home Health Resource Group
(HHRG).

413
Q

OBSERVATION STATUS

A

A condition under which clients who appear in the emergency department (ED) but need a little more time after their ED stay to sort out whether they truly need
admission to an acute care/hospital setting as inpatients. Care for these clients
usually lasts less than 24 hours although sometimes may extend to a few days. Clients classified as observation status receive their care and services either in the
ED itself or another part of the acute care hospital.

414
Q

OCCUPATIONAL DISEASE

A

A health condition or illness a worker experiences that is associated with the job
responsibilities or work environment (e.g., hearing loss, emphysema, chronic obstructive pulmonary disease).

415
Q

ODG

A

Official Disability Guidelines

416
Q

OIG

A

Office of Inspector General

417
Q

OSHA

A

Occupational Safety and Health Administration

418
Q

ONGOING RISK
STRATIFICATION

A

A process in which case managers assign clients to risk groups upon or after they access a healthcare practice setting or enrollment in a health insurance
plan and perhaps are receiving care. Case managers in this case update the risk stratification level of the client using administrative data such as claims data or assessments such as the health risk assessment (HRA) and various screening tools.

419
Q

OUTCOME

A

The result and consequence of a healthcare process. A good outcome is a result that achieves the expected goal. An outcome may be the result of care received or not received. It represents the cumulative effects of one or more processes on a
client at a defined point in time.

420
Q

OUTCOME INDICATORS

A

Measures of quality and cost of care. Metrics used to examine and evaluate the results of the care delivered.

421
Q

OUTCOMES MANAGEMENT

A

The use of information and knowledge gained from outcomes monitoring to achieve optimal client outcomes through improved clinical decision making and The use of information and knowledge gained from outcomes monitoring to
achieve optimal client outcomes through improved clinical decision making and
service delivery service delivery.

422
Q

OUTCOMES MONITORING

A

The repeated measurement over time of outcome indicators in a manner that permits causal inferences about what client characteristics, care processes, and resources produced the observed client outcomes.

423
Q

OUTLIER

A

Something that is significantly well above or below an expected range or level.

424
Q

OUTLIER THRESHOLD

A

The upper range (threshold) in length of stay before a client’s stay in a hospital becomes an outlier. It is the maximum number of days a client may stay in the hospital for the same fixed reimbursement rate. The outlier threshold is determined by the Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA).

425
Q

OVERUTILIZATION

A

Using established criteria as a guide, determination is made asto whether the client is receiving services that are redundant, unnecessary, or in excess.

426
Q

OWCP

A

Office of Workers’ Compensation Programs

427
Q

PANEL OF PROVIDERS

A

Usually refers to the healthcare providers, including physicians, who are responsible for providing care and services to the enrollee in a managed care
organization. These providers deliver care to the enrollee based on a contractual agreement with the managed care organization.

428
Q

PARTIAL DISABILITY

A

The result of an illness or injury which prevents an insured from performing one or more of the functions of his/her regular job.

429
Q

PATHOPHYSIOLOGY

A

The physiology of abnormal states; specifically: the functional changes that accompany a particular syndrome or disease

430
Q

PATIENT CENTERED
MEDICAL HOME (PCMH)

A

An approach to providing comprehensive, holistic and integrated primary care for clients. It is a care setting that facilitates partnerships among individual clients, client’s support systems and their primary care providers. Healthcare services
in such setting is facilitated by disease registries, information technology, health information exchange and other means to assure that clients receive the necessary care when and where they need or desire it, in a culturally and linguistically
appropriate manner

431
Q

PATIENT SELF-DETERMINATION ACT OF 1991 (PSDA)

A

Refers to patients’ (i.e., clients’) rights to specify if they want to accept or refuse specific medical care and identify a legal representative for urgent healthcare decision purposes (known as advance directive including healthcare proxy). Then
if they become unable to make decisions for themselves as a result of a serious illness (e.g., stroke resulting in a coma), the patients then receive healthcare
services based on their wishes which have already been clearly documented at an earlier point of time when patients were healthy or through their healthcare proxy’s decisions.

432
Q

PATIENT’S BILL OF RIGHTS

A

A law that ensures that all clients receive individualized, patient/family-centered,
considerate, and respectful medical care and treatments. It also emphasizes the client’s right to be well informed of and educated about the diagnosis, prognosis, and indicated treatment and care options. In addition, it states that a client has the right to self-determination: to agree to or refuse treatment and be informed of the consequences of such decisions.

433
Q

PAYER

A

The party responsible for reimbursement of healthcare providers and agencies for
services rendered such as the Centers for Medicare and Medicaid Services and
managed care organizations.

434
Q

PAYOR

A

Principal Term: The person, agency, or organization that assumes responsibility for funding the health and human services and resources consumed by a client. The payor can be the client her/himself, a member of the client’s support system, an employer, a government benefit program (e.g., Medicare, Medicaid, TriCare), a commercial insurance agency, a charitable organization or others.

435
Q

PAYOR REPRESENTATIVE

A

The person or organization representing the payor (healthinsurance agency).
This individual is able to speak and make decisions on behalf of the payor and can be a case manager, a physician, medical advisor, claims manager or a quality management specialist.

436
Q

PAYOR SOURCES

A

The individual or agency responsible for the expenses incurred during a client’s healthcare encounter; either commercial insurance, government programs,
charitable organization, personal/self pay or others.

437
Q

PECS

A

Patient Evaluation Conference System

438
Q

PCP

A

Primary Care Provider

439
Q

PEER REVIEW

A

Review by healthcare practitioners of services ordered or furnished by other practitioners in the same professional field.

440
Q

PEER REVIEW
ORGANIZATION (PRO)

A

A federal program established by the Tax Equity and Fiscal Responsibility Act of 1982 that monitors the medical necessity and quality of services provided to Medicare and Medicaid beneficiaries under the prospective payment system.

441
Q

PER DIEM

A

A daily reimbursement rate for all inpatient hospital services provided in one day to one client regardless of the actual costs to the healthcare provider. The rate can vary by service (medical, surgical, mental health, etc.) or can be uniform regardless
of intensity of services.

442
Q

PERFORMANCE
IMPROVEMENT

A

The continuous study and adaptation of the functions and processes of a healthcare organization to increase the probability of achieving desired outcomes and to better meet the needs of clients.

443
Q

PERITRANSITION

A

The period that surrounds a client’s transition: before, during, and after a transition.

444
Q

PERMANENT AND
STATIONARY (P&S)

A

When the condition of a worker who is suffering from a work-related injury or illness has plateaued to the point that additional medical treatment is not likely to improve the worker’s condition. This point signals the end of temporary disability
benefits and the need to examine the likelihood of permanent benefits instead.

445
Q

PERMANENT PARTIAL
DISABILITY (PPD)

A

Disability that is caused by either a work-related injury or an occupational illness resulting in some form of permanent impairment that makes a worker unable to perform at his/her full capacity. An example is loss of vision in one eye or amputation of a finger in one hand.

446
Q

PERMANENT PARTIAL
DISABILITY BENEFIT

A

A benefit payable to the employee for a life-long disability resulting from an on-the-job injury or illness and loss of function that is partial in nature. It is payable based on a percentage loss rating given by the authorized treating physician
in accordance with current guidelines. The benefit percentage is calculated by a formula that contains number of weeks assigned by the State Workers’ Compensation or Disability Board multiplied by the percentage rating of the
permanent partial disability.

447
Q

PERMANENT TOTAL
DISABILITY

A

The worker’s wage-earning capacity is permanently and totally lost as a result of a work-related injury or illness that has deemed the worker unable to completely recover and therefore unable to return to work in any capacity.

448
Q

PERMANENT TOTAL
DISABILITY BENEFIT

A

The benefit payable to workers who are never able to return to gainful employment after a work-related injury or illness. In this case there may not be any limit on the number of weeks the benefit is payable. In certain instances an employee may continue to engage in business or employment if the earned
wages combined with the weekly benefit do not exceed the maximums set by law.

449
Q

PER-MEMBER-PER-MONTH
(PMPM)

A

The typical reimbursement method used by HMOs, it refers to a fixed amount of money paid to a care provider for covered services rather than based on specific services provided. Whether a member uses the health service once or more than
once, a provider who is capitated receives the same payment.

450
Q

PERSON-CENTERED CARE

A

Care being provided “that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions

451
Q

PETITION

A

An application to a court ex parte paying for the exercise of the judicial powers of the court in relation to some matter that is not the subject for a suit or action, or for authority to do some action that requires the sanction of the court.

452
Q

PH

A

Personal Health

453
Q

PHR

A

Personal health record

454
Q

PHYSICAL DISABILITY

A

A bodily defect that interferes with education, development, adjustment or rehabilitation; generally refers to crippling conditions and chronic health problems but usually does not include single sensory handicaps such as blindness or deafness.

455
Q

PHYSICIAN-HOSPITAL
ORGANIZATION

A

Organization of physicians and hospitals that is responsible for negotiating contractual agreements for healthcare provision with third-party payers such as managed care organizations.

456
Q

PLAINTIFF

A

A person who brings a suit to court in the belief that one or more of his/her legal right have been violated or that he/she has suffered legal injury.

457
Q

PLANNED RISK
STRATIFICATION

A

A process in which case managers assign clients to risk groups– before the clients have the need to access a healthcare program or practice setting – to then accurately assess their needs and appropriately plan for their necessary care and services.

458
Q

PLAUSIBILITY

A

Refers to something that has the appearance of being true but which actually might be deceptive – sometimes innocently deceptive and sometimes speciously so. Examining plausibility is necessary for determining whether observed change is a direct result of applied interventions.

459
Q

PLAUSIBILITY CHAIN

A

The process of examining whether plausibility indicators (factors or a sequence of events) were present and affected the link between observed change and applied intervention(s). An unbroken plausibility chain validates that the applied
intervention(s) indeed contributed to the observed outcomes.

460
Q

PLAUSIBILITY INDICATOR

A

A factor or sequence of events that if present usually interrupt the likelihood that the observations made are a direct by- product of the applied intervention(s). Plausibility indicators perform similar to how confounding variables act in a
research study and affect the observed outcomes.

461
Q

PMI

A

Project Management Institute

462
Q

POA

A

Present on Admission

463
Q

POC

A

Plan of care

464
Q

POS

A

Point of service

465
Q

POINT OF SERVICE (POS
PLAN)

A

A type of managed care health insurance plan which combines characteristics of both the HMO and the PPO plans. Members of a POS plan do not make a choice about which approach or plan to use until the point at which the service is needed and is being or about to be used. This plan also requires members to choose a PCP who in turn is responsible to make necessary referrals to SCPs or other healthcare services needed even if outside the plan’s network of providers. Members usually pay substantially higher costs in terms of increased premiums, deductibles and coinsurance.

466
Q

POLYPHARMACY

A

A term used to denote “many or multiple drugs.” It refers to problems that can occur either when a client is taking more medications than are actually needed or even when prescribed medications are clinically indicated. It is a particular
concern for older adults but also widespread in the general population. Most common issues are increased drug-to-drug interactions, adverse drug events, higher costs, and medication errors.

467
Q

POSITIVE PREDICTIVE VALUE
(PPV):

A

Proportion of clients who are predicted to experience high-cost services that turn out to be truly high cost.

468
Q

POST-ACUTE CARE

A

The post-acute care delivery systems focus on the provision of services needed by a client after experiencing an acute episode of illness. Post-acute care settings may include skilled care facilities, long-term care, home care services, rehabilitation and sub-acute care facilities, palliative care or hospice, as well as
residential, group homes or assisted living facilities.

469
Q

POST-TRANSITIONING
COMMUNICATION

A

One of the nine steps of a case management process, it involves contacting the client and/or client’s support system to check on the client’s condition and
determine how the ongoing treatment is progressing after the initial transition process.

470
Q

PPO

A

Preferred provider organization

471
Q

Prospective Payment System (PPS)

A

A healthcare payment system used by the federal government since 1983 for reimbursing healthcare providers/agencies for medical care provided to Medicare and Medicaid participants. The payment is fixed and based on the operating costs of the patient’s diagnosis.

472
Q

PRACTICE GUIDELINES
(GUIDELINES)

A

Systematically developed statements on medical practices that assist a practitioner in making decisions about appropriate diagnostic and therapeutic healthcare services for specific medical conditions. Practice guidelines are usually
developed by authoritative professional societies and organizations such as the
American Medical Association.

473
Q

PRACTICE SETTING/SITE

A

Principal Term: The organization or agency (or work setting) at which case managers are employed and execute their roles and responsibilities. These may
include but not be limited to payor, provider, government, employer, community, independent/private, workers’ compensation or client’s home environment.

474
Q

PRE-ACUTE CARE

A

The pre-acute care delivery systems focus on health maintenance and prevention
(primary and secondary) of illness or unnecessary progression/deterioration in a client’s health condition. They usually require the least complex and least costly services. Pre-acute care settings may include clinic or outpatient treatment
centers, community care, educational and health maintenance environments or
payor (health insurance plan) organizations. Examples of services offered in such settings are health screening, lifestyle behavioral modification (healthy living) and disease risk reduction.

475
Q

PREADMISSION
CERTIFICATION

A

An element of utilization review that examines the need for proposed services before admission to an institution to determine the appropriateness of the setting, PRECEDENTprocedures, treatments, and length of stay.

476
Q

PRECEDENT

A

A decision by a judge or court that serves as a rule or guide to support other judges in deciding future cases involving similar or analogous legal questions.

477
Q

PRECERTIFICATION

A

The process of obtaining and documenting advanced approval from the health plan by the provider before delivering the medical services needed. This is
required when services are of a nonemergent nature.

478
Q

PRECERTIFICATION REVIEW

A

Also known as preadmission review or prospective review. A review that occurs prior to the delivery of any healthcare services to a client to determine the appropriateness, necessity and relevance of the services and obtain authorization from the health insurance plan for the services to be rendered to the client.

479
Q

PREDICTIVE MODELING

A

A process used in data mining, usually automated and employs specialized software application to create a statistical model of future behavior that forecasts
probabilities and trends. The model is made up of a number of variables or factors called predictors that are likely to influence future behavior or results. In case management, for example, factors may include client’s gender, age, frequency of
access to healthcare services, number of chronic illnesses, and lifestyle behavior.

480
Q

PREDICTOR

A

A characteristic or variable that is likely to influence a client’s future access to, or utilization of, healthcare services and resources. It tends to project the pattern of utilization. Examples are gender, age, frequency of past access to healthcare
services (e.g., hospitalizations and visits to the emergency department), biometrics (e.g., cholesterol level), number of chronic illnesses, and lifestyle or
health risk behaviors (e.g., smoking, alcohol consumption, and use of controlled substances).

481
Q

PRE-EXISTING CONDITION

A

A physical and/or mental condition of an insured which firstmanifested itself prior
to the issuance of the individual policy or which existed prior to issuance and for which treatment was received.

482
Q

PREFERRED PROVIDER
ORGANIZATION (PPO)

A

A program in which contracts are established with providers of medical care. Providers under a PPO contract are referred to as preferred providers. Usually the
benefit contract provides significantly better benefits for services received from preferred providers, thus encouraging members to use these providers. Covered persons are generally allowed benefits for nonparticipating provider services, usually on an indemnity basis with significant copayments.

483
Q

PREMATURE DISCHARGE

A

The release of a client from care before he or she is deemed medically stable and ready for terminating treatment/care (e.g., discharging a patient from a hospital when he or she is still needing further care and/or observation).

484
Q

PREMIUM

A

The periodic payment required to keep a policy in force.

485
Q

PREPAID HEALTH PLAN

A

Health benefit plan in which a provider network delivers a specific complement of
health services to an enrolled population for a predetermined payment amount.

486
Q

PRIMARY CARE

A

The point when the client first seeks assistance from the medical care system. It also is the care of the simpler and more common illnesses.

487
Q

PRINCIPAL DIAGNOSIS

A

The chief complaint or health condition that required the client’s admission to the hospital for care.

488
Q

PRINCIPAL PROCEDURE

A

A procedure performed for definitive rather than diagnostic treatment, or one that is necessary for treating a certain condition. It is usually related to the primary diagnosis.

489
Q

PRINCIPLE

A

A widely recognized and accepted rule of action, behavior, or conduct.

490
Q

PRO

A

Peer Review Organization

491
Q

PROFESSIONAL DISCIPLINE

A

Principal Term: The case manager’s formal education, training and specialization
or professional background that is necessary and pre-requisite for consideration as a health and human services practitioner. It is also the professional background
case managers bring with them into the practice of case management such as
nursing, medicine, social work, rehabilitation and others as deemed appropriate.

492
Q

PROJECT MANAGEMENT
INSTITUTE (PMI)

A

The world’s leading not-for-profit organization for the project management
profession that offers a range of services such as the development of standards, research, education, publication, networking-opportunities,
conferences and training seminars, and multiple related credentials.

493
Q

PROSPECTIVE PAYMENT
SYSTEM (PPS)

A

A healthcare payment system used by the federal government since 1983 for reimbursing healthcare providers/agencies for medical care provided to Medicare and Medicaid participants. The payment is fixed and based on the operating costs of the client’s diagnosis.

494
Q

PROSPECTIVE REVIEW

A

A method of reviewing possible hospitalization before admission to determine necessity and estimated length of stay.

495
Q

PROVIDER-RELATED
OUTCOMES

A

Consequences or results of care activities, processes, or services that are directly related to the provider of care (e.g., case manager, physician, or healthcare agency).

496
Q

PSDA

A

Patient Self-Determination Act of 1991

497
Q

PSYCHOPATHOLOGY

A

The study of psychological and behavioral dysfunction occurring in mental illness or in social disorganization

498
Q

PSYCHOSOCIAL CONDITION

A

The client’s economic, educational, social, psychological, emotional, cultural, and religious attributes (e.g., values, beliefs, rituals, and habits) that affect the client’s health status and behavior.

499
Q

PUBLIC POLICY

A

The course of action to address an issue of concern by the community at large in terms of laws, regulations, legislation, decision, or any action in general. Shaping public policy is a complex and multifaceted process that involves the interplay of numerous individuals and interest groups competing and collaborating to
influence policymakers to act in a particular way.

500
Q

QOL

A

Quality of Life

501
Q

QUALIFIED REHABILITATION
PROVIDER

A

PROVIDER

Also referred to as qualified rehabilitation counselor, vocational counselor,
rehabilitation nurse, or qualified rehabilitation professional. A vocational rehabilitation counselor who is registered with the workers’ compensation or
disability agency in the jurisdiction of employment (e.g., the Department of Labor
and Industry in Minnesota). Generally, an applicant for the qualified rehabilitation
provider professional status must show eligibility based on specific criteria such as certification as a certified rehabilitation counselor (CRC) or certified disability management specialist (CDMS), internship as a rehabilitation professional, and/or work experience.

502
Q

QUALIFIED REHABILITATION
VENDOR (QRV)

A

An individual or business that provides vocational and/or general rehabilitation services to clients based on registration in a state or jurisdiction that grants
permission to provide such services to clients in that jurisdiction. Services provided aim mainly to secure gainful employment for the client and may include but are not limited to medical services, training opportunities, vocational
assessment and training, and/or use of specialized equipment that minimize the impact of the disability.

503
Q

QUALITY ASSURANCE

A

The use of activities and programs to ensure the quality of patient care. These activities and programs are designed to monitor, prevent, and correct quality deficiencies and noncompliance with the standards of care and practice.

504
Q

QUALITY IMPROVEMENT

A

An array of techniques and methods used for the collection and analysis of data gathered in the course of current healthcare practices in a defined care setting
to identify and resolve problems in the system and improve the processes and outcomes of care.

505
Q