CCMC GLOSSARY OF TERMS

Transformational leader

A Charismatic and futuristic leader who is able to inspire motivate guide mentor challenge and support his or her followers especially during the change process

Supplementary medical insurance

A secondary medical insurance plan used by a subscriber to supplement health care benefits and coverage provided by the primary insurance plan. The primary and secondary supplementary plans are unrelated and provided by two different agencies.

Independent living

A service delivery concept that encourages the maintenance of control over one's life based on the choice of acceptable options that minimize for reliance on others performing every day activities

Cultural competency

A set of congruent behaviors attitudes and policies that come together in the system, agency, among professionals and enables the system, agency or professionals to work effectively in cross cultural situations.

Accountable Care organization (ACO)

A set of healthcare providers including primary care physicians, specialist and hospitals that work together collaboratively and accept collective accountability for the cost and quality of care delivered to a patient population. (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 multi specialty medical groups, physician hospital organizations and organized or integrated delivery systems.

Instrumental activities of daily living

A set of skills necessary for an individual to maintain independent living. Requires emotional and physical capacity for successful performance.

accreditation (n)

A standardized program for evaluating healthcare organizations to ensure a specified level of quality as the defined by a set of national industry standards. Accreditation entails a voluntary survey process that assesses the extent of a healthcare organization compliance with the standards for the purpose of improving the systems and processes of care performance and in doing so improving outcomes.

Change management

A structured and systematic approach or process organized to move an organization program or team of individuals from one current to future desires states. Some of the tactics applied in the change management process include communicate effectively, and Power staff, minimize resistant, enhance adoption of change, establish and execute roadmap for change, ensure sustainability and achieve success.

Capacity

A construct that indicates the highest probability level of functioning a person may reach. Capacity is measured in a uniform or standard environment and that reflects the environmentally adjusted ability of an individual

adhesive contract

A contract between two parties where one party with stronger bargaining power sets the terms and conditions and the party which is the weaker of the two with to no ability to negotiate must adhere to the contract and is placed in a "take it or leave it" position

Release

A contract in which one party forfeits the right to pursue a legal claim against the other party.

Vocational rehabilitation counselor

A counselor who specializes in vocational counselor guiding handicapped person in the selection of a vocation or occupation

Fraud

A deliberate deception intended to secure an unfair or unlawful gain

Case management department

A division within a healthcare organization

Assumption of Risk

A doctrine based upon voluntary exposure to a known risk. It's distinguished from contributory negligence, which is based on carelessness in that it involves a comprehension that a peril is to be encountered and willingness to encounter it.

Report card

A emerging tool that is used by healthcare providers purchasers policymakers governmental agencies and consumers to compare and understand the actual performance of health plans and other service delivery programs. He usually includes data and major areas of accountability such as quality utilization of resources consumer satisfaction and cost.

Plausibility indicator

A factor or sequence of events that is present until interrupted the likelihood that the observations made are a direct byproduct of the applied interventions. Plausibility indicators perform similar to how confounding variable's act in a research study and affect observed outcomes.

Medicare

A federal program of health insurance for persons 65 years of age and older

Capitation

A fixed amount of money per member per month paid (PMPM)to a caregiver for a covered services rather than based on specific services provided. The typical reimbursement method used by HMOs.

Disability income insurance

A form of health insurance that provides periodic payments to replace income when is your purse this on able to work as a result of illness injury or disease.

Petition

A formal request

Casualty insurance

A general class of insurance and Worker's Compensation insurance

Rehabilitation team

A group of healthcare workers with backgrounds and rehabilitation work together to provide integrated client oriented care.

Rehabilitation counseling

Assist individuals with disabilities in adapting to the environment assist in Birmingham and accommodate the needs of individual and working towards for participation a persons with disabilities and all aspects of society and especially work.

Community alternatives

Agencies outside and institutional setting was provides care support and services to people with disabilities

AHQR

Agency for Healthcare Research and Quality

BAS

Burden assessment scale

Psychosocial condition

Clients economic, educational, social, psychological, emotional, cultural, and religious attributes that affect the clients health status and behavior.

Discharge outcomes criteria

Clinical criteria to be met before or at the time of the clients discharge.

Inter-disciplinary

Collaboration among different discipline that address connected aspects Of the clients to find health problems or needs.

Workers compensation

An insurance program that provides medical benefits and replacement of lost wages for person suffering from injury or illness that is caused by or occurred in the workplace. Insurances some for Industrail and work injury regulated primarily among the separate states regulate in certain specified occupations by the federal government

CCMC

Commission for case manager certification

CARF

Commission on Accreditation of Rehabilitation Facilities

CARS

Community assessment risk screen

Beneficence

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

Acuity

Complexity and severity of the clients health/medical condition.

CPR

Computer Based Patient Record

Model

Conceptual or a graphic representation of an object one phenomenon. It usually depicts the relationship among the key parts or ideas and thoughts of the phenomenon.

Health risk assessment

Conducted to identify the presence of risk and determine how such risk may influence health-seeking behavior access to healthcare services.

Client related outcomes

Consequences or results of care activities, processes, or services that are directly related to the clients condition, health status, or situation.

COBRA

Consolidated Omnibus Budget Reconciliation Act

Underutilization of resources

Consuming less healthcare resources and services the necessary or indicated when Caring for an individual patient

litigation

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

performance improvement

Continuous study and adaptation of the functions and processes of a healthcare organization to increase the probability of achieving desired outcome and to better meet the needs of the clients

Scholarly activities

Creative work that is. You and publicly communicated or Wildly disseminated. Refer to achievements in knowledge acquisition, evaluation, utilization Or application such as writing publishing teaching research mentoring public speaking community engagement or obtaining a post graduate level degree.

CPT

Current Procedural Terminology

Job development

Customize employment process that consists of an individualized the determination of a person strength capabilities requirements and interest. Custom mise work exploration and planning. Development of a customized employment relationship with potential or actual employers. How lining of the support necessary for employment to be successful.

Inpatient rehabilitation facilities patient assessment instrument

Diagnostic used to classify patient into distinct groups based on clinical characteristics and expected resource needs. The PAI term is the case mix group classification.

activity limitations

Difficulties an individual may have in executing activities. An activity limitation may range from a slight to a severe deviation in terms of quality or quantity in executing the activity in a manner or to the extent that is expected of people without the health condition

Disability

Diminished function, based on an anatomic, physiological or mental impairment that has reduce the individual security or prism ability to engage in any substantial gainful activity

Temporary total disability TTD

Disability that completely prevent an injured worker from returning to work after a work related injury or illness for a limited period of time.

Permanent partial disability

Disability that is caused by either a work related injury or an occupational illness resulting in some form of permanent impairment that makes it work or unable to perform at his/her for capacity.

Total disability

Disabled to the point where no work is possible.

DMAA

Disease management Association of America

Discharge status

Disposition of a client at discharge i.e. left against medical advice expired discharged home or transferring to a nursing home

Justice

Do you ethical principle that involves the idea of fairness and equality in terms of access to resources and treatment by others.

Life care plan

Document based on publish standards of practice, comprehensive assessment, research, and data analysis, which provides an organize concise plan for current and future needs with associated costs, for individuals who have experienced catastrophic injury or have chronic health care needs.

Health care proxy

Document designating a legal decision maker for medical decisions

loss reserve

Dollar amount designated as the estimate cost of a accident at the time the first noticed is received

Social security disability insurance

Federal benefit program sponsored by the Social Security administration. Primary factor disability and or benefits received from deceased or disable parent, Benefit depends upon money contributed to the Social Security program either by the individual or parent

Peer Review Organization

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.

FCM

Field Case Management

HMO (Health Maintenance Organization)

GroupModel, individual practice association (IPA) network model and staff model. Must be an organized system for providing healthcare in a geographical area. Agreed on-set of basic and supplemental health maintenance and treatment services. Voluntarily enrolled group of people.

Care guidelines

Nationally recognized and professionally support plan of care recommended for the care management of clients with a specific diagnosis or health condition and in a particular care setting. Usually develop based on the latest available evidence and modified as necessary by healthcare professionals upon implementation for the care of an individual. Also called the case management plan.

Medicare Part A covers

Hospital and hospice care

HINN.

Hospital issued notice of non-coverage

Vocational assessment

Identifies the individuals strength Skills interest abilities and rehabilitation needs. Accomplish through on site situational assessment at local businesses in the community settings.

Catastrophic case

Medical condition or illness that has high medical social and financial consequences that respond positively to the controlled offered through a systematic effort of the case management.

Important message from Medicare

Notice of discharge from the acute care setting that hospitals are required to deliver to our Medicare patients.

Staff model HMO

Most rigid HMO MODEL. Positions are on the staff of the HMO with some sort of salaried position and provide care exclusively for the health plan enrollees

MAP

Multidisciplinary action plan

NASW

National Association of Social Workers

NCQA

National Committee for Quality Assurance

NPP

National Priorities Partnership

NQF

National Quality Forum

Recovery audit contractor

National program within centers for Medicare and Medicaid services that aim to guard into improper Medicare payments and fight fraud, waste, and abuse in the Medicare program and is designed to guard the Medicare Trust fund

NACCM

Nationally Academy of Certified Care Managers

Loss expense allocated

Part of the expense paid by the insurance company in settling a claim such as legal fees by excluding the payment to the claimant

Non-adherence

Person's behavior that does not correspond with agreed-upon recommendations from a healthcare provider or demonstrates inability or indifferent about following the recommendations such asking to tobacco use despite the instructions to give up smoking

PH

Personal Health

PHR

Personal Health Record

Stratify risk

Process that is used to classify clients into one of three health risk categories. Low moderate and high based on a set of predetermined criteria and use a health assessment and bio medical screening tools. Stratify risk is important for determining an adequate level of intervention as appropriate to each clients specific situation and treatment plan.

Ongoing risk stratification

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 Manager update the risk stratification level of client using data (health risk assessment) HRA

Nursing Case Management

Process model using the components of case management in the delivery aspects of nursing care.

Planning

Process of determining and documenting specific objectives, goals and actions designed to meet the clients needs as identified through the assessment process. The plan should be action orientated and time specific

Medication reconciliation

Process of examining and monitoring all medications taken. Determining their compatibility, Saturday, safety in order to reduce the number of adverse drug effects and promote adherence to the medication regimen.

Plausibility chain

Process of examining whether plausibility indicators factors or sequence of events were present and affected the link between observe change and applied intervention. And unbroken plausibility chain validates that apply to intervention in the contributed to the observed outcomes.

Implementation

Process of execution specific case management activities and or interventions that Will lead to accomplishing the goals set forth in a case management plan

Root cause analysis

Process used by healthcare providers and administrators to identify the basic or causal factors that contribute to variations in performance and outcomes or underlie the occurrence of the sentinel event.

Predictive modeling

Process used in data mining usually Automated and employees 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 call predictor that are likely to influence future behavior or results. In case management, for example, factors mu clue clients gender age frequency of access to healthcare services number of chronic illnesses and lifestyle behaviors.

Malpractice

Professional negligence wrongful conduct

Disability management program

Program that focuses on assisting workers who have suffered from occupational health conditions or job related injuries return to work. It facilitates accommodations and workplaces to prevent impairment incidence of injured workers from becoming disability circumstances.

standards of care

Statement that delineates care that is expected to be provided to all clients. They include predefined outcomes of care clients can expect from providers and are accepted within the community of professional based upon the best scientific knowledge current outcomes data and clinical expertise

Actuarial study

Statistical analysis of a population based on its utilization of healthcare services and demographic trends of the population. Results used to estimate healthcare plan premiums or cost

Transitioning

Step of the case management process consists of activities such as assessing whether the client is ready for transfer or discharge home reviewing the treatment plan also the client support system in the home warranty for healthcare facility or transfer to a community-based clinician for further treatment and follow-up

Stratification groups

Stratification classes or stratification levels. Categorized into groups based on health risks status which may include low moderate or high risk stratification.

Work rehabilitation

Structured program of graded physical conditioning strengthening exercises and functional task in conjunction with real or simulated job activities. Treatment is designed to improve the individuals cardio pulmonary neuromusculoskeletal strength endurance movement flexibility stability and motor control function bio mechanical human performance levels and psychosocial aspects as they relate to the demands of work. Work rehabilitation provides a transition between acute care and return to workWhile addressing the issues of safety physical tolerances work behaviors and functional abilities.

Transformational leadership

Style of leadership that affects positive and desire changing people, systems, program or organizations. It relies on defining Vision for the future inspires people to change motivates people to actively participate in the change process and capitalizes on the effects of collaboration between leaders and followers to achieve expected goals and vision.

SME

Subject Matter Expert

SIB

Supplemental income benefits

Managed Care

System of healthcare delivery that aims to provide a generalize structure in focus when managing to use excess costs quality and effectiveness of Healthcare Services.

Outcome measurement

Systematic, quantitive observation, at a point in time, Of outcome indicators.

Practice guidelines

Systematically developed statements for specific clinical circumstances

Protocol

Systematically written document about a specific clients problem. This mainly use as it integral component of a clinical trial or research. It also Delineates the steps to be followed for particular procedure or intervention to meet desired outcomes

Inter-disciplinary care team (ICT)

Team of healthcare professionals and paraprofessionals from different disciplines what departments within an organization who are all involved in the care of a client, share common care goals and who have responsibility for a complementary task, interventions, and/or treatments necessary to meet the clients goals.

Demand management

Telephone triage and one line health of my services to reduce members avoidable visit to health providers. This helps reduce unnecessary costs and contributes to better outcomes by helping members become more involved in their own care

Polypharmacy

Term used to denote many or multiple drugs. Refers to problems that can occur when a client is taking more medication than actually need it or even prescribe medications are clinically indicated. Particularly concerning for older adults

Medicare secondary payer

Term used when Medicare program does not have primary payment responsibility.

Case closure

Terminating the provision of case management services to a client or support system. The process of communicating the surgeon to terminate services to clients support systems pay or representative and other healthcare professionals involved.

Contactual ethics

Terms and conditions of the contract or at the Cole in contacts in my spirit here to buy them by all parties.

Handoffs

The act or an instance of passing something or the control of it from one person or agency to another. And Health Care context handoff of passing of accountability and responsibility for clients care from one clinician to another within the care setting or across care settings. The act is especially necessary during transition of care situations.

Process

The actual and necessary steps taken to complete a specific task not to produce a desired outcome

Habilitation

The process by which a person with development of this abilities is assisted in acquiring to maintain a life skills. Cope more effectively with personal and developmental demands. Increase the level of physical mental vocational and social ability through services.

Discovery

The process by which one party to a civil suit can find out about matters that are relevant to his or her case, including information about what evidence the other side has, what witnesses will be called

Evaluation

The process for repeated at appropriate intervals, of determining and documenting the case management plans effectiveness in reaching desired outcomes and goals. This is my little modification or change in the case management plan and it's entirety or its component parts

Discharge planning

The process of assessing the clients needs of care after discharge from a healthcare facility and ensuring that the necessary services are in place before discharge. This process is yours a client timely, appropriate, and safe discharge to the next level of care or setting include the proper use of resources necessary for ongoing care.

Job placement

The process of assisting a injured worker to find employment by matching the workers skills knowledge and abilities with a potential job.

Assessing

The process of collecting in-depth information about a client and her/his support system in order to identify the needs and decide upon the best case management services to address these needs. Similar to screening, however to a greater depth.

Assessment

The process of collecting in-depth information about a person 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.

Case-based review

The process of evaluating the quality and appropriateness of care based on the review of individual medical records to determine whether they care delivered is acceptable.

Disability case management

The process of managing occupational and not occupational diseases with that aim of returning the disabled employee to a productive work schedule and employment.

Transitions of care

The process of moving patients from one level of care to another usually from the most to the least however depending on the patient health condition and needed treatment the transition can occur from least to most as well

Waiver

The process of moving patients from one level of care to another, usually the most to the lease complex however depending on the patient's health condition and the needs of treatment the transition can occur from least to the most complex.

Pre-authorization/Pre-Certification

The process of obtaining an documenting advance approval for the health plan by the provider before Delivery the medical services needed.This is required when services are a non-emergent nature

Screening

The process of reviewing key information related to an individual's health situation medical condition as well as psychosocial and financial status for the purpose of identifying the need for case management services

Appeal (legal in nature)

The process whereby a court of appeals review 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 courts decision.

Delegation

The process whereby an organization permits another entity to perform functions and assume responsibilities on behalf of the organization, while the organization retains final authority to provide oversight to the delegate.

Risk sharing

The process whereby the HMO and the contracted provider each except partial responsibility for the financial risk and reward involved in cost-effectively caring for the members enrolled in the plan and assigned to a specific provider

Risk

The uncertainty of loss with respect to Person, liability or the property of the insured or the probability that revenues of the new sure will not be sufficient to cover expenditures be cured in the delivery of contract for services.

Health Care home

The usual Setting or level of care the client select to use as a routine basis to receive healthcare services such as a large or small medical group, single practitioner, and community health center, or hospital outpatient clinic.

Use value

The utility of Consuming a good or service and the satisfaction of experience as a result of it

Client source

The way a case manager comes in contact with the client to provide case management services, usually taking place either by referral or family healthcare provider, a member of the client.

Clinical review criteria

The written screens, decision rules, medical protocols, what Guidelines used to evaluate medical necessity Certified vocational evaluator, appropriateness and level of care.

Cognitive rehabilitation

Therapy programs which a person is in managing specific problems and perception, memory, thinking and problem-solving skills or practice and strategies are taught to help improve function and compensate for remaining deficits.

telephone triage

Triaging patients to appropriate levels of care based on a telephonic assessment of the client. Case manager is using the find a use of their telephone based assessment to categorize the client to be an emergent urgent or not urgent condition.

Sanction

Type of action CCMC imposes on a board certified case manager cited in a complaint of alleged violations of the code of professional conduct for case managers after careful review of the complaint. The sanction may for example be in the form of a reprimand, suspension of the certified case managers for dentures, or placement of the case manager on probation.

Inter-active voice response (IVR)

Type of communication technology that allows individuals to interact with others via technology rather than actual people (telephone or voice recognition systems)

Point of service

Type of managed care health insurance plan was combines characteristics of both the HMO and a 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 services is needed and is being or about to be used. The plan requires members to choose a PCP who in turn is responsible to make necessary referrals to specialist. Members usually pay substantially higher cost in terms of increased premiums deductibles and coinsurance.

Per member per month

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

Knowledge framework

What case managers need to now to actively care for patients. Includes a nice step case management process and 7 essential knowledge domain applicable in any cheer practice setting up for the various healthcare professionals with all the case managers role.

Telephonic case management

When a case manager provides care coordination and management services virtually via the telephone and or other modes of electronically vacation. Usually TCM programs are supported by state of the art software systems digital tools and communication technologies.

Early return to work

When a worker who have suffered a job related injury or illness resumes work before a complete recovery and while still suffering from some sort of partial disability. Usually the early return to work may involve the same job but with modify responsibilities.

SMI

supplemental medical insurance

frame of reference

a set of ideas that determine how a person understands something

Interrogatories

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 disposition

COB

coordination of benefits

living will

stating one's wishes about life support and other treatments

THROUGHPUT

Client flow through the systems of care within a healthcare organization

Brain disorder

A loosely used term for a neurological disorder or syndrome and Indicating impairment or injury to the brain tissue

Indicator

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

Utilization review

A mechanism used by some insurers and employers to evaluate health care services on the basis of appropriateness necessity and quality

settlement

A meeting of the mind of parties to a transaction or controversy which resolve some issues involved in a case.

Rule of conduct

A model behavior or a set of behaviors professionals such as case managers are expected to exhibit or emulate during their practice and when dealing with clients and other professionals or members of the public. These usually reflect what is commonly understood as ethical behavior and or a good standing in the community. For example maintaining professional behavior and being truthful.

Certified nurse life care planner

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.

Conditional rehabilitation professional

A rehabilitation professional who has not yet met all the requirements to be qualified rehabilitation professionals

Concurrent review

A review of the health record while the patient is still hospitalized or under treatment. There's also a form of utilization review that tracks the consumption of resources and the progress of clients while they are being treated.

Credentialing

A review process to approve a provider who applies to participate in a health plan. Specific criteria are applied to evaluate participation in the plan. The review may include reference training experience demonstrated ability, licensure verification and adequate malpractice insurance

peer review

Review by healthcare practitioners of service order or furnished by another practitioner in the same professional field

Precertification review

Review that occurs prior to the delivery of any healthcare services to a client to the terminal 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. Also known ass preadmission review or perspective review

Prospective review

Reviewing possible hospitalization before admission to determine necessity and LOS

activities of daily living (ADLs)

Routine Activities and individual tends to do every day for self-care and normal living. These include eating, bathing, grooming, dressing, toileting, transferring and continence. Assessment of an individuals ability to perform these ADLs is important for determining an individuals ability, independence, disability, or limitations. The 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.

Regulations

Rules, mandate, orders, or restrictions issued by and executive authority or regulatory agency usually government related and having the force of law, for the purpose of controlling behavior and communicating key expectations. And healthcare regulations and to standardize care promote client safety and enhance quality

Home health resource groups

Rupees for perspective reimbursement under Medicare for home healthcare agencies. Placement and to HHRG is based on the oasis score. Reimbursement rates correspond to the level of home health provider

Ergonomics

Scientific discipline concerned with understanding of interactions among humans and other elements of the system. It is the profession that applies. Principles data and methods to environmental design including work environment in order to optimize human well-being and overall system performance.

Indemnity

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

Carve out

Services excluded from a provider contract that may be Covered through arrangements with other providers providers are not financially responsible for services carved out of their contract.

Certified vocational rehabilitation provider

A vocational rehab practitioner who is registered in the Worker's Compensation agency or convention in the state of employment.

Principle

A widely recognized and excepted rule of action behavior or conduct

Letter of Instruction

A written statement expressing concern with a board certified case manager action in regards to the CCMC Code of Professional Conduct.

Affidavit

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

Tort feasor

A wrong doer who is legally liable for damage caused

caseloads

The total number of clients followed by case manager at any point in time.

DRGs

diagnosis-related groups

POC

plan of care

Formulary

A list of prescription drugs approved by a health plan.

Current Procedural Terminology

A listing of descriptive terms and I didn't find cold for reporting medical services and procedures performed by healthcare providers are usually use for billing purposes

Temporary partial disability benefits

A benefit payable to win employee when he or she returns to work in a job painless as a result of it on the job accident. These benefits are payable for up to 350 weeks from the date of the injury. This lost wage amount is 2/3 of the difference between the employees average weekly wage before and after the injury. The maximum amount payable cannot exceed the maximum allowed under the law.

Civil cases (suits)

A case brought by one or more dividual sick wear dress of some legal injury or aspect of an injury for which there are several remedies.

Board certified case manager

A case manager who has earned a certified case manager credential offered by the CCMC. This involves passing and evidence-based certification examination after meeting a set of criteria that qualifies the case manager to sit for the examination. One certified the case manager must maintain certification by acquiring ongoing education through means of continuing education units and upholding the CCM Code of professional conduct for case managers.

Lien

A charge or security of encumbrance upon property

Tort

A civil wrong committed against a person or property, excluding breach of contract. May recover money damages arising from breach.

Gag Rule

A clause in a provider contract that prevents doctors or other providers from revealing a full range of treatment options to clients.

Knowledge domain

A cluster of health and human services group together based on a common thing 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 health care reimbursement

Case management

A collaborative process that assesses plans implements coordinates monitors evaluates the options and services required to meet the clients health and human services needs. It is characterized by advocacy communication and resource management and promotes quality and cost effective interventions and outcomes.

Healthcare Delivery system

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

Case management plan of care

A comprehensive plan of care for an individual client that describes the problems needs and desires determined based upon finding of the client assessment. Strategies such as treatments and individuals to be instituted to address the problem Anthony. Measurable goals including specific outcomes to be achieved to Demonstrate resolution of the problems and the the timeframe for achieving them the resources available and to be used to realize the outcomes and the desires of the client that may have an impact on the plan

Case management body of knowledge

A comprehensive resource of essential knowledge in the field of case management. Master and become knowledgeable skilled as well as experienced in to effectively care for clients and their support system and be considered a competent case management practitioner

Job Bank Service

A computerized system developed by the department of labor that maintains an up-to-date listing of job vacancies available through the state employment services.

Case management model

A conceptual or a graphic representation of the practice of case management and organization. It's usually the pics the relationships among the key function and stakeholders of case management and the roles and responsibility of case managers.

Pre-existing condition

A condition that existed before the policy went into effect

Decision rule

A logical statement of characteristics, conditions, or attributes that explains the appropriate of making a specific decision or choice.

Aggregated Diagnosis Groups (ADGs)

A grouping of diagnosis codes that are similar in terms of severity and likelihood of persistence in a clients health condition over time. (ADG) total of 32 ADG clusters. Individual disease or conditions are placed into a single ADGs based on a set of criteria including likely persistence of diagnosis, severity of illness, etiology, diagnostic certainty and need for speciality care interventions.

case manager

A health and human service professional horse responsible for coordinating the overall care services

Medicaid

A health care payment program sponsored by federal & state governments. Basic health insurance for persons with disability or are poor.

Individual practice association

A health maintenance organization model of insurance that contract with a private practice physician or healthcare Association to provide healthcare services in return for a negotiated fee.

Care management

A healthcare delivery process that helps achieve better health outcomes by anticipating and linking clients with the services they need quickly. It also helps avoid unnecessary services by preventing medical problems from escalating.

Sub acute care facility

A healthcare facility that is a step down from an acute care hospital and a step up from a conventional skilled nursing facility intensity of services.

Prospective payment system

A healthcare payment system used by the federal government since 1983 for reimbursing healthcare providers for medical care provided to Medicare and Medicaid patients.

Continuous quality improvement

A key component of total quality management that uses rigorous, systematic, organization-wide process to achieve office ongoing improvement in the quality of healthcare services and operation. It focuses on both outcomes and processes of care.

Patients bill of rights

A law that you sure stack all clients receive individualize, patient/family center, considerate, and respect for medical care and treatment. Also emphasizes the right to be well informed and educated about diagnoses.

Actionable Tort

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

Hospital issued a notice of noncoverage

A letter provided to patients informing them of insurance not cover is in case they refuse hospital discharge or insist on going to hospitalization despite the review by the pier review organization that indicates their readiness for discharge.

Alternate levels of care

A level of care that can safely be used in place of the current level and determined based on he acuity and complexity of the clients condition and the type of needed services and resources.

Transitional care nurse

A nurse who in Mary Naylors transitional care model helps to plan and execute smooth discharges for high-risk patient

Oasis

A nursing assessment instrument completed by home health agencies at the time the patients entered for home health services. This scoring determines the home health resource group (HHRG)

RETURN TO WORK (RTW)

A organized systematic way of managing employees absence from work due to illness or injury and the process for returning to work a soon as possible if appropriate.

Return on investment

A performance measure used to evaluate the benefit of a product service or intervention such as case management relevant to its related expense or cost. The result is expressed as a percentage or ratio

License

A permit to practice medicine or health profession that is issued by state and required for performance of job function

guardians

A person appointed by the court to be a substitute decision-maker for a person is receiving services team to be incompetent of making informed decisions for themselves. The powers of a guardian are determined by a judge and maybe limited to certain aspects of the persons life.

Self determination

A person centered and directed process when one decides what is necessary and desirable to create a personally meaningful and satisfactory life. Process differs from person to person and egg knowledges the rights of people, especially those who are ill or disabled. For example the individual not the service system decides where he or she will live and with Home, what type of services he was she requires and who will provide them.

Stakeholders

A person group or organization that has direct or indirect steak in a program or organization because it can affect or be affected by the organization's actions object if's policies mission vision and objectives.

Advocate

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

Adjuster

A person who handles claims also referred to as a claims service representative

Claim service representative

A person who investigates losses in Settles claims for an insurance carrier also known as a adjuster.

Barrier free

A physical man-made environment or arrangement of structures that is safe and accessible to persons with disability

Disability

A physical or neurological deviation in an individual make up. May refer to a physical mental or sensory condition. May or may not be a handicap to an individual, depending on one's adjustment to it.

Transition plan

A plan detailing goals and services for transitioning to post-secondary activities

withold

A portion of payments to a provider held by the manage care organization until end of year that will not be returned to the provider unless specific target utilization rates are achieved. Typically used by HMO to control utilization of referral services by the Gate keeper

Quality indicator

A predetermined measure for assessing quality. Also known as metric

Commission on Accreditation of Rehabilitation Facilities

A private nonprofit organization that establishes standards of quality for service to people with disabilities and offers voluntary accreditation for rehabilitation facilities based on a set of nationally recognized standards

Confidential communication

A privileged communication that may be disclosed only with the patient's permission.

Vocational counseling

A process of assisting individuals to obtain work especially those with disability weather developmental in nature or due to injury or illness. Consist of job seeking counseling services that are provided by vocational counselor and includes evaluation of skills after two values areas of interest learning how to improve the skills guidance on how to successfully search for a potential job and develop strategies for effectively applying and interviewing for a job.

Quality monitoring

A process used to ensure that care is being delivered at or above acceptable quality standards and as identified by the organization or national guidelines

Social work

A profession whose primary concern is how human needs can be met within society.

Certified Vocational Evaluatior

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

Vocational rehabilitation professional

A professional who works with an interdisciplinary healthcare team to help eligible individuals with disabilities attain and maintain competitive employment. Overcome psychological developmental cognitive and health barriers so that these individuals are able to obtain Lena for jobs and increase their independence.

Work adjustment training

A program for person who's disabilities limit them from obtaining competitive employment. Typically includes a system of goal directed services focusing on improving problem areas such as attendance, work stamina, punctuality, dressing and hygiene, interpersonal relationships with coworkers and supervisors. Services can get to you until objectives are met or until there has been noted progress. May include practical work experiences or extended employment

Work hardening

A program that focuses on work endurance and uses real or simulated job task and duties and progressively graded conditioning exercises based on the workers measured tolerance to ultimately return to work or to Gainful employment.

job accommodations

A reasonable adjustment to a job or work environment that makes it possible for an individual with disability to perform job duties

active listening

A structured way of communication and interacting in which one is actively engaged with the speaker primarily through focused attention and suspension of ones own frame of reference, biases, distraction and judgment. A communication technique that improves personal relationships fosters understanding and facilitate cooperation and collaboration and eliminate conflict

Incentive

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

Disease management

A system of coordinated health care interventions and communications for populations with chronic conditions in which the client self-care efforts are significant. Supports the physician client relationship.

Common law

A system of legal principles that does not arrive it's authority from statutory law, but from general usage and custom up evidence my decision of the court.

Searchable online accommodation Resource (Soar)

A system that is designed in a way to allow users to explore various accommodation options for persons with disabilities and work and educational settings.

Chronic care model

A systematic model that proposes several basic and specific elements for improving care in health systems at the community, organization, practice and individual clients level. If she was delivery of high-quality chronic disease care to clients with chronic illnesses. The elements of the model include community, health system, self management, delivery system design, decision support and Do use of clinical information systems.

functional capacity evaluation

A systematic process of assessing and individuals physical capacities and functional abilities. Establish the physical level of work and individual can perform. Can provide objective information regarding functional workability in the determination of occupational disability status.

Cost benefit analysis

A technique or systematic process used to calculate and compare the benefits and cost of an action intervention service or treatment and to determine how well or how poorly it will turn out.

Developmental retardation

A term that has been suggested as a replacement for mental retardation. Removes confusion with mental health and mental illness.

Accessible

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

Experience

A term used to describe the relationship, usually in a percentage or ratio, a premium to claims for the plan, coverage, or benefits for a stated period time.

International classification of diseases ninth revision, clinical modification (ICD-9-CM)

A text formulated to standardize diagnosis. Use for Cody medical records in preparation for reimbursement particularly in the inpatient care setting

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 develop prospectively by and interdisciplinary healthcare team in relation to a patient's diagnosis health problems or surgical procedure.

Actuary

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

Co insurance

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

Medical necessity on admission

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

Continued stay review

A type of review used to determine that you stay out of the hospital stay is necessary and they care is being rendered at the appropriate level it takes place during the clients hospitalization for care.

dichotomous variable

A variable known to have only two characteristics for options when evaluated in a particular study or predictive modeling. For example characteristics maybe high or low true or false yes or no present or absent.

Standards of Practice

Acceptable level of performance or expectations for professional intervention or behavior Associated with one professional practice.

Statue

Act of a legislature declaring commanding opera having an action in contrast to unwritten common law.

Quality assurance

Activities and programs were sure of the quality of patient care. The activities and programs are designed to monitor prevent the correct quality deficiencies in noncompliance with the standards of care and practice.

Transition management

Activities case managers engage in twin sure if active safe equality transitions of clients from one care setting or provider to another. These may add a minimum include assessment of clients needs and readiness to transition.

ADL

Activities of Daily Living. ROUTINE ACTIVITIES carried out for personal hygiene and health and For operating a household. ADLs include feeding, bathing, showering, dressing, getting in or out of bed or a chair, and using the toilet.

Severity of illness

Acuity of illness criteria That identifies the presence of significant debilitating symptoms deviation from the clients normal levels or unstable abnormal vital signs or laboratory findings

Intensity of service (IS)

Acuity of illness criteria based on the evaluation/treatment plan, interventions and anticipated outcomes

Third-party administration

Administration of a group insurance plan by some person or firm other than that you sure of the policyholder.

ASO

Administrative Services Only

Handicap

Advantage and limitation a potential based on a physical or mental impairment or disability that subsequently and then it's up against the fulfillment of one or more major life activities otherwise considered normal for that individual based on a sex and social and cultural factors.

Stipulation

Agreement between opposing parties that a particular fact or principle of law is true and applicable

Consensus

Agreement in opinions of experts building consensus is the method used when developing case management plans.

autonomy (n)

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

Independent case management

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 a salaried employees in a privately owned case management firm.

Significant event

Also known as sentinel events. And unexpected occurrence that is unrelated. To the natural course of illness medical treatment or case management interventions which result in death series physical or psychological injury or permanent disability or loss of function.

Gold standard

Also known as the idea practice, refers to the best available knowledge evidence or benchmark under reasonable or similar conditions

Actual Value - Predicted Value

Also referred to as real value. Measures the worth one derives from using or consuming a good product, product, service or an item and represent the utility of the good, products, service or item

Work modification

Altering the environment to accommodate a persons physical or mental limitations by making changes and equipment in the methods of completing task or in job duties.

APC

Ambulatory Payment Classification

AAPM&R

American Academy of Physical Medicine and Rehabilitation

AHA

American Heart Association

AMA

American Medical Association

ANA

American Nurse Association

ANCC

American Nurses Credentialing Center

ADA

American with Disabilities Act of 1990

ADA Amendment Act (ADAAA)

Americans with Disabilities Act Amendments Act of 2008

Bench marking

An act of comparing a work in process with that of the best competitor. Through this process one is able to identify what performance measure levels must be surpassed. Bench marking assist and organization in assessing it's strengths and weaknesses and in finding and implementing best practices.

Patient centered medical home

An approach provide a comprehensive, holistic and integrated primary care for clients. Care setting that facilitates partnership of mom individual clients, support systems, primary care providers. Healthcare services is so settings is facilitated by disease management, information technology, health information exchange in other news to assure that the member receives the necessary care when and where they need to, and a culturally an appropriate manner.

Community Assessment Risk Screen

An assessment tool used to determine the risk for rehospitalization or emergency department admittance of elderly clients.

Standard (Individual)

An authoritative statement by which a profession of the defines the responsibilities for which it's practitioners are accountable

Inclusive education

An educational model in which the students with disabilities receive their education in a general educational setting with collaboration between general and special education teachers.

Preadmission certification

An element of utilization review that examines the need for propose services before a mission to an institution to determine the appropriateness of the setting, procedure, treatments, and length of stay

Ambulatory payment classification (APC) system

An encounter based classification system for outpatient reimbursement including hospital based clinics, emergency department observation and ambulatory surgery. Payment rates are based on categories of services that are similar in cost and resource utilization.

Jurisdiction

An entity possessing official power to make legal decisions and judgments based upon the authority granted to it.

Agreed Medical examination

An evaluation conducted by a provider who is selected by agreement between an injured workers attorney and the Insurance claims administrator and/or attorney. The parties agree to conduct a medical examination and prepare a medical legal report to help resolve an existing dispute. The evaluation also serves to determine what portions of the work related injury have contributed to the disability and what portions have resulted from sources or causation.

Utilization review accreditation commission

An independent nonprofit organization that promotes health care quality through accreditation education and measurement programs. It's main mission focused on promoting continuous improvement in the quality and efficiency of healthcare management through processes of accreditation and education. Offers a wide range of quality benchmarking services, validates the commitment of healthcare organizations to quality and accountability through accreditation and ensures that all stakeholders are represented it in establishing meaningful quality measures for healthcare industry

Beneficiary

An individual eligible for benefits under a particular plan. In managed-care organizations beneficiaries may also be known as members in HMO plans or enrollees in PPO plants.

Ergonomist

An individual who has a mastery of ergonomics knowledge. Command of the methodology. Has applied his or her knowledge to the analysis design test and evaluation of a product or process and environment.

Captive

An insurance company formed by an employer to assume it's Worker's Compensation and other risk and provider services.

Third-party payor

An insurance company or organization responsible for the cost of care so that individual clients do not directly pay for services

Administrative Services Only (ASO)

An insurance company or third party administrator (TPA) that delivers administrative services to an employer group. This usually requires the employer to be at risk for the cost of healthcare services provided which the ASO processes and manages claims.

Second opinion

An opinion obtained from another physician regarding the necessity for treatment and has been recommended by another physician. May be required by some health plans for certain type of cases such as cardiac surgery.

Job club

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

Third Party Administrator (TPA)

An organization that is outside of the Insurance organization that handles only administrative functions such as capitalization review and processing claims. Third-party administrators are used by organizations that actually fun the health benefits but do not find it cost-effective to administer the plan themselves.

Relative weight

And assigned weight that is intended to reflect the relative resource consumption associated with each DRG. The higher the relative weight the greater the payment or reimbursement to the hospital.

Case mix complexly

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

Health

And individuals physical, functional, mental, behavioral, emotional, cognitive condition, psychosocial. Refers to the presence or absence of illness, disability, injury or limitation was require special attention for management and resolution including the use of health android human service type interventions and resources.

Domestic carrier

And insurance company organize and headquartered in a given state is referred to in the state as a domestic carrier

Claims adjusters

And insurance professional who investigates claims by interviewing the claimant and other involved parties, reviews related records to determine degree of liability and damages, I shores that and then Shorince policy exists and covers the claimed damages.

Case management program

And organized approach to the provision of case management services to clients. The program is usually described in terms of vision mission and objectives. The number and type of staff including roles responsibilities and expectations. A specific model or a conceptual framework resource utilization and management bed capacity clinical documentation quality and berries management and others depending on the healthcare organization.

Contempt of court

Any act that is calculated to embarrass in their delay or obstruct the court in the administration of justice or that is calculated to lessen its authority with dignity

Brain injury

Any damage to tissues of the brain that leads to impairment of the function of the central nervous system

Provider

Any group or individual who provides health care services.

Catastrophic illness

Any medical condition or illness that have high medical, social, and financial consequences and responds positively to the control offer through a systematic effort of case management services.

Developmental Disability

Any mental and or physical disability that has onset before age 22 and maybe continue indefinitely. It can Limit major life activities. Individuals with mental retardation Sarabel palsy autism epilepsy sensory impairments congenital disabilities Trumatic brain injury or condition is caused by disease i.e. polio and muscular dystrophy may be considered developmentally disabled.

Assistive Technology Services

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

adverse events (AEs)

Any untoward occurrences which under most conditions are not natural consequences of the clients disease process or treatment outcomes.

Health Benefit plan

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

Quality improvement

Array of techniques and methods used for 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 process and outcomes of care.

Discharge screen

Assessment of client/support Discharge needs using a set of criteria that results in a Denna find clients who are to benefit from healthcare services or resources Post an episode of illness and or to prevent leave for acute care rehospitalization

Standard (Organization)

Authoritative statement that defines the performance expectations structures or processes that must be substantially in place in an organization to enhance the quality of care

Release of information

Authorization to send the patient's information to another physician

Medicaid Waiver

Authorized under section 1915(C) Of the social security act, provide states with greater flexibility to serve individuals with substantially long-term care needs at home or in activity rather than in an institution. The federal government Waives certain medication. This allows a state of like a portion of the population on Medicaid to receive special life service is not available to have Medicare recipients.

Diagnosis related group

Classification scheme that provides a means of relating the type of patient in hospital trees to the cost incurred by the hospital. DRGs may be primary or secondary. Also is a form of reimbursement the CMS use it to pay hospitals for Medicare and Medicare recipients.

Level of Service

Based on the member condition and the needed level of care used to identify and verify that the client is receiving care at the appropriate level

Core Therapies

Basic therapy services provided by professionals on the rehabilitation unit. Using refers to nursing physical therapy occupational therapy speech language pathology social work therapeutic recreation and neurophysiology

Permanent partial disability benefits

Benefit payable to the employee for a lifelong disability resulting from on the job injury or illness and loss of function that is partial in nature. Payable based on percentage loss ratio given by the authorizing treating physician in accordance with current guidelines. 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.

Permanent total disability benefits

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. Insert is this is an employee may continue to engage in business or employment if the earned wages combined with the weekly benefit do not exceed the maximum set by law

Pre-paid health plan

Benefit plan which a provider network delivers a specific complement of health services to an enrolled population for a predetermined human amount. Also known as capitation

Disability benefit

Benefits for most Americans are covered and pay by the Social Security administration through either two main group programs Social security disability insurance (SSDI) for those who have worked in recent years or supplemental security insurance (SSI) for low income individuals who are disabled or have become disabled and on able to return to work.

Indemnity benefits

Benefits in the form of payment rather than services. In most cases after the provider have built the client will be a short person is reimbursed by the company.

Temporary total disability benefits

Benefits payable to win employee who is injured on the job and I'm able to work as determined by the authorized treating physician. The amount is 2/3 of the employees average weekly wage at the time of the injury not to exceed the maximum amount allowed under the law. For not catastrophic injuries benefit our limit it to 400 weeks from the date of injury if the injury occur on or after July 1, 1992 for catastrophic injury benefits are unlimited.

BOK

Body of knowledge

Resource utilization groups (RUGs)

Classify skilled nursing facility patients into 7 major hierarchies and 44 groups. Based on the MDS the patient is classified into the most appropriate group and with the highest reimbursement.

Executive function

Capacity of a persons working memory which relies on one state of condition, attention, after two, intellectual capacity, mental processes, ability to maintain focus, and the ability to handle a breadth of ideas and facts

Observation status

Care for these clients usually last lesson 24 hours via the ER. Evaluated for admission to acute care hospital setting for discharge home.

Skilled care

Client care services that require delivery by a licensed professional such as a registered nurse or physical therapist occupational therapist speech pathologist or social worker.

Healthcare Continuum

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

Strategy

Careful and well thought out plan, method, scheme or series of steps applied for the purpose of achieving a specific goal or result

CMI

Case Mix Index

CMAG

Case management adherence guidelines

CMBOK

Case management body of knowledge

Transitional planning

Case manager supply to a sure that appropriate resources and services are provided in the most appropriate study or level of care. Focus on moving a patient from most complex to less complex care setting.

Professional discipline

Case managers formal education/training and specialization background that is necessary and is a prerequisite for consideration as a health and human service practitioner. It is also the professional background case managers bring with them into the practice of case management such as nursing Madison social work rehabilitation.

No exparte communication

Case managers on the no circumstances can discuss the medical treatment plan with the treating physician separate from the workers who suffered a work related injury or illness.

CMGs

Case mix group

Lost wages benefits

Case of wages due to a job related disability and extended absence from work.

Re-review

Case review that is completed based on your request from the health insurance plan after denial or reimbursement of services have been recommended by the plan to the healthcare provider. The insurance plan for the ducks this type a review in an effort to reconsider the denial decision especially after an appeal has been submitted by the provider of care on behalf of the client.

Scholarships

Cash allowances awarded to students to pay education costs.

HCC Hierarchical Condition Category

Categories of clients grouped based on clinical coding information and diagnostic groups used to identify Medicare high cost chronic conditions Diabetes and Kidney disease. These groups are targeted for adjustment and Medicare Capitate payment for private health plans for the health expenditure risk of these enrollees

CMS

Centers for Medicare and Medicaid Services

Hospital value-based purchasing program

Centers for Medicare and Medicaid services established to reward acute care hospitals with incentive payments for the quality of care they provide to Medicare beneficiaries. The rewards hospitals receive is based on the quality of care, best practices and care during hospital stay

CCM

Certified Case Manager

CVE

Certified vocational evaluator

Predictor

Characteristic or Variable that is likely to influence the clients future access to, or utilization of, healthcare services and resources.

Structure

Characteristics or key elements that describe the environment of care and practice that have a direct or in direct impact on outcomes of care.

Third party workers compensation claim

Claimed that involves a party other than or in addition to the workers employer but this party place a role in the workers claim for benefits due to the injury related disability that prevents the worker from returning to give full implement.

Bona fide

In good faith

Per diem

Daily reimbursement rate for all inpatient hospital services provided in one day regardless of the actual cost to the provider. Rate can vary by service or can be uniform regardless of the intensity of service.

distributive justice

Deals with the morals basis for the dissemination of good and evil, burgers and benefits, especially when making decisions regarding the allocation of healthcare resources.

DBA

Defense Based Act of 1941

Telephonic case management

Delivery of healthcare services to clients and our families or caregivers over the telephone or through correspondence such as fax email or other forms of electronic transfers.

DDHS

Department of health and human services

Adjusted Clinical Groups (ACG) System

Developed by the school of public health at Johns Hopkins University, this system cluster clients into homogenous groups based on a unique approach to measuring morbidly 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 clients health records

Mentoring

Developmentally oriented relationship between two individuals.

Variance

Deviation from the norm standard or what is expected. Depending on the situation it may result in an undesired outcomes such as the lady care a medical error or a clients dissatisfaction. Variance categories and include system, patient, practitioner in community.

Negligence

Failure to take proper care in doing something

Electronic medical record

EMR

Visual impairment

Educationally defined as deficiency in eyesight to the extent that special provisions are necessary in education.

Motivational interviewing

Effective communication techniques applied to gather important information and obtain insight into the situation and health condition, focusing on clinical, social, financial, mental behavior and emotional aspect of the member status. Telecommunication is supportive, empathic and counseling like that helps move towards desirable change

Loss Control

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

EMTALA

Emergency Medical Treatment and Active Labor Act

ERISA

Employee Retirement Income Security Act of 1974

EN

Employment Network

Job coach

Employment specialist who provides training and support to the person in the workplace.

EBP

Evidence-based practice

EPO

Exclusive Provider Organization

Dual relationships

Exist when the case manager has responsibilities towards a third-party other than the client i.e. case manager/pair/client or case manager/employer/client.

EDSS

Expanded disability status scale

Barriers

Factors in a persons environment that if absent or present limits ones functioning and creates disability.

Lobbying

Form of Advocacy whereby an individual or group attempts to influence decisions made by those in positions of authority/ power

Supplemental job displacement benefit

Form of benefit that is used to cover the cost of training and injured worker to return to an existing job or a new job altogether. It is a voucher of limit financial amount often does not exceed $10,000 and they cover the cost of training or education, skills enhancement, certification examination and or licensure.

Admission Certification

Form of utilization review in which an assessment is made of the medical necessity of a clients 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.

Compliant

Formal Expression of concern that a board-certified case managers behavior does not adhere to CCMC called a professional conduct of the case managers at standards, rules procedures and penalties.

Quality management

Formal and planned, systematic, organizationwide approach to monitoring, and analysis and improvement of organization performance, thereby continually improving the extent to which providers conform to the defined standards, the quality of client care and services provided and the likelihood of achieving desired outcomes

Structured care tools

Formal approaches to streamlining care practices and activities for the purpose of reducing practice pattern variations among healthcare providers, avoiding unnecessary cost of healthcare services, and establishing best practice standards while maintaining and improving the quality of care provided.

WeeFIM

Functional Independence Measure for Children

bad faith

Generally involve the actual or constructive fraud or a design to mislead or deceive another.

Benefit programs

Government agency or employer to individuals based on some sort of an agreement between the parties. Benefits very 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 an accidental death counseling and other therapies such as chiropractic care.

Injury

Harm or damage to a person

HCFA

Health Care Financing Administration

HIT

Health Information Technology

HIPPAA

Health Insurance Portability and Accountability Act

HRA

Health Risk Appraisal

HEDIS

Healthcare Effectiveness Data and Information Set

Community services and resources

Healthcare programs that offer specific services and resources in the community based environment as opposed to an institutional setting that is outside the confines of the healthcare facilities such as hospitals and nursing homes. These programs by either publicly or privately funded or charitable in nature.

Special care provider

Healthcare provider with a specific area of expertise. Requires a referral from PCP.

episode of care (EOC) option

Hey client access to healthcare services with a healthcare provider. It's individual clients specific , Time-limited and always has a beginning and an end. The length of the counter varies based on healthcare needs the type and intensity of required services to effectively address the need.

precedent

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

Coding

Hey mechanism of identifying and defining client care services activities as primary and secondary diagnosis and procedures.The process is guided by the ICD nine coding manual which list the various Kohls in their respective description. Colt is usually done in preparation for reimbursement for services provided.

Catastrophic injury

Hey serious injury that resulted in severe and long-term effects on the individual who sustains it going permanent severe functional disability. Examples are Trumatic brain spine or spinal cord injury multiple trauma and loss of any major body part.

HCC

Hierarchical Condition Category

Social media

Highly accessible technologies that facilitate communication, interaction and connection with others

Occupational disease

Illness resulting from conditions associated with employment

Physical disability

Impairment in certain function(s) of the body, such as vision, hearing, or mobility.

IM

Important message from Medicare

Disability

Inability or limitation and performing task, activities, and rolls in the manner or within the range considered normal for a person of the same age, gender, culture and education. Can also refer to any restriction or lack of ability to perform an activity in the manner or within the range consider normal for a human being.

Sensory aphasia

Inability to understand the meaning of written, spoken or tactile speech symbols because of the disease or injury to the auditory and visual brain centers

Lost wages

Income a worker does not earn due to inability to return to work as a result of a work related disability or extended absence

Supplemental income benefits

Income benefits and injured worker received on a monthly basis after applying for and found deemed to meet the eligibility requirements which include an impairment rating of 15% or more. Have not returned to work because of impairment or have return to work but only less than 80% of the average weekly wage and prior to the injury because of the impairment. This benefit is only paid after impairment income benefits end.

Impairment

Indicating injury, deficiency or lessening of function. Impairment is a condition that is medically determined and related to the loss or abnormality of psychological, physiological or anatomical structure or function.

IPE

Individual Plan for Employment

IPA

Individual Practice Association

Payor sources

Individual or agency responsible for the expenses incurred during a members health encounter

Qualified rehabilitation vendor

Individual or business that provides vocational and or general rehabilitation services to clients based on registration in the state or jurisdiction of the grants permission to provide such services to clients in that jurisdiction. Assist with securing a full employment to include but not limited to medical services training opportunities vocational assessment and the use of specialized equipment that minimize the impact of the disability.

Lobbyists

Individual such as a advocate who attempts to influence the decision of those in positions of authority with the primary goal of promoting a special agenda

Client

Individual who is the recipient of case management services.

IWRP

Individual written Rehabilitation program

Self-care management

Individual's ability to make day-to-day decisions about the management on illness. It is also one self efficacy and confidence to carry out certain activities of daily care and demonstrate behaviors necessary to reach health goals.

IPE

Individualized Plan for Employment

Residual functional impairment

Individuals capacity to perform job related task physical and cognitive or mental despite functional limitations that exist as a result of a job related injury or illness. In the Worker's Compensation field this is formally assessed by experts to determine the workers ability to gain fully do you activity and therefore return to work in some capacity.

Funding systems

Individuals or agencies that provide financial resources to support the care of those who are poor, vulnerable, like health insurance coverage or unable to independently assume such responsibility.

Carpal tunnel syndrome

Inflammation of the tendons passing through the carpal tunnel of the wrist

Not disabling injury

Injury which may require medical care but does not result in loss of work time or income

IRF-PAI

Inpatient Rehabilitation Facility-Patient Assessment Instrument

IHI

Institute for Healthcare Improvement

IOM

Institute of Medicine

Long Term disability income insurance

Insurance issued to an employee, group, or individual to provide a reasonable replacement of a portion of the employees earned income loss through a prolonged illness

IDS

Integrated Delivery System

IS

Intensity of Service

ICT

Interdisciplinary Care Team

Services

Interventions, medical treatment, diagnostics, or other activities implement it to manage a clients condition including health and human services issues and needs. Can be found in case management plan of care, medical treatment plan or other related documents as applicable to the setting in which the member receives care.

Functional independence measure

It's an 18 item instrument with an ordinal scale ranging from one total assistance to seven complete independence That is used in medical rehabilitation settings to measure a clients ability to function with independence.

JCI

Joint Commission International

KPSS

Karnofsky Performance Status Scale

Multidisciplinary Action Plan

Known as Case management plan. Timeline of patient care activities and expected outcomes of care that address the plan of care of each discipline involved.

Field case management

Known as on-site case management. A form of here coordination and management where my case manager worked with the client in person rather than virtually via telephone or electronic waves of your location.

Learning disability

Lack of achievement or ability in a specific line area within the range of achievement of individuals with culpable mental ability. Most definitions emphasize a basic disorder in psychological process involved in understanding and using language spoken or written.

Nurse licensure compact

Legal agreement that allows nurses based enacted laws to have one multi state license lower down the ability to practice in both their home and other states that have a group to belong to the compact.

Medical durable power of attorney

Legal document that needs a Sarah get decision-maker in the event that the person becomes unable to make his or her own healthcare decisions.

Veracity

Legal principle that states that a health professional should be honest and give for disclosure, abstain from misrepresentation or deceit, report no lapses of the standards of care to the proper agency.

Tort Liability

Legal requirement that a person responsible, or at fault, Shall pay for the damages and injuries caused

liability

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

advance directive

Legally executed document that the clients healthcare related wishes and decisions. It's drawn up while the client is still competent and is used if the client becomes incapacitated or incompetent

LORS

Level of Rehabilitation Scale

Respondeat superior

Literally let the master respond. This maxim means that an employer is liable in certain cases for the wrongful acts of his or her employees and the principal for those of his and her agency

Hearing

Live proceeding done before a formal body with decision making authority. Allows the decision making body to determine the outcome and share its conclusion with the opposing party

LHWCA

Longshoremen's and Harbor Workers' Compensation Act

Reasonable accommodation

Making existing facilities use my employee readily accessible and usable by individuals with disabilities. This may include job restructuring, part time or modify work schedules, acquisition or modification of equipment or devices and other similar accommodations for individuals with disabilities.

MCO

Managed Care Organization

Management services organization

Management entity owned by hospital, physician organization or third party. It contracts with payers and hospitals supervisor in healthcare management services such as negotiated fee schedule and handling administrative functions including Utilization management billing and collections

Utilization management

Management of health services to ensure that went offer they are medically necessary, provided in the most appropriate care studies and at or above quality standards.

Licensure

Mandatory an official form of validation provided by a governmental agency in any state affirming that a practitioner have acquired the basic knowledge and skills and minimum degree of competency required for state practice.

Plaintiff

Person who bring a suit to court in the believe that one or more of his legal rights have been violated. Or that he has suffered legal injury.

Continuum of care

Matches ongoing needs of the individual's been 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.

MMI

Maximum Medical Improvement

Outcome indicators

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

MLR

Medical Loss Ratio

MSP

Medicare Secondary Payor

MET

Metabolic equivalent of task

Beyond (outside) the walls case management

Models where healthcare resources services in case managers are Based externally to an acute care hospital setting that is in the community

Within the walls case Management

Models where healthcare resources, services and case manager are based within the acute care hospital setting

Reed MD Guidelines

Nationally recognized disability management, workers compensation and return to work guidelines used by clients employer and clinician to predict disability duration and this return to work time for various disease and injuries. Guidelines considers the risk, capacity and tolerance. Improves disability outcomes employees health and company productivity.

Milliman care guidelines

Nationally recognized guidelines that offer integrated diagnosis-specific reference, footnotes and abstract. Used to help drive quality of care especially in the use of medical resources. Focused on reducing variances from best practices. Delivery of client centered care

InterQual Criteria

Nationally recognized standards that describe when and how an individual client with a specific health condition. Acute care/hospitals, behavioral health, and payor focusing on care planning, levels of care, clinical evidence summaries and retrospective monitoring.

Denial

No authorization or certification is given for healthcare services because of the inability to provide justification of medical necessity or appropriateness of treatment or length of stay. This can occur before during or after care provision

Project management Institute

Non-for profit organization for the project management profession that offers a range of services such as the Bella Mente of standards, research, education, publication, networking opportunities, conference and training seminars in multiple related credentials.

NLC

Nurse License Compact

Transitions coach

Nurse social worker or train volunteer helps clients acquire self-management skills related to transition care

OSHA

Occupational Safety and Health Administration

Admission review

Occurs within 24 hours of a clients admission to a healthcare facility or according to the time frame required in the contractual agreement between the healthcare provider and health insurance plan. This review ensures that the clients care in an inpatient setting is necessary based on the clients health condition and intensity of services needed.

OIG

Office of Inspector General

OWCP

Office of Workers' Compensation Programs

ODG

Official disability guidelines

Individual written rehabilitation program

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 and Daily living.

Workers compensation commission

One of the many times I didn't find the state public body which and ministers the Worker's Compensation laws, holding hearings on contested cases, promotes industrial safety, we have billet Tatian. It is often located within the state labor department. The national organization is the international Association of industrial accident boards and commissions.

Monitoring

Ongoing process of gathering sufficient information from all relevant sources and it's documentation regarding the case management plan. Enables the case manager to determine the plans effectiveness.

Physician hospital organization

Organization of physicians and hospitals that is responsible for negotiating agreement for Health Care provision with third-party payers such as managed-care organizations.

Practice setting/site

Organization or agency or work Setting at which case managers are employed and execute their roles and responsibility.They may include but not be limited to pair, provider, government, employer, community, independent/private, Worker's Compensation or client home environment.

ancillary services

Other diagnostic and therapeutic services that may be involved in the care of clients other than nursing or medicine. Include respiratory, laboratory, radiology, nutrition, physical and occupational therapy and pastoral services.

OASIS

Outcome and Assessment Information Set

End result outcomes

Outcomes that occur at the conclusion of an episode of care and that indicates achievement of target goals. For example decided to transition a client from an acute care to home after successful tolerance Oral antibiotics or transitioning a Worker's Compensation client back to work after successful job modification interventions.

encounters

Outpatient or ambulatory visit by health plan member to a provider.

Prospective payment system

PPS

Positive predictive value

PPV

Supported employment

Paid employment for persons with developmental disabilities who without long-term support are unlikely to succeed in a regular job. Supported employment facilities provide competitive work in integrated work settings for individuals with the most severe disabilities for home competitive employment has not traditionally occurred in who because of the nature is the beauty of their disability need ongoing support services in order to perform your job.

PMCH

Patient Centered Medical Home

PECS

Patient Evaluation Conference System

PSDA

Patient Self-Determination Act

Assignment of benefits

Paying medical benefits to a provider of care rather than 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.

Reimbursement

Payment regarding healthcare services provided by physician medical person or agency.

PRO

Peer Review Organization

PPD

Permanent partial disability

Informed consent

Permission granted voluntarily by a person who is of sound mind and aware of all factors involved

Fiduciary

Person and a special relationship of trust, confidence or responsibility in which one party occupy the Sapir your relationship and the song is the duty to act in the defendants best interest. Includes trustee, guardian, counselor or institution but it could also be a volunteer at it in the special relationship.

Metabolic equivalent of task

Physiologic measure that expresses the energy cost of physical activity and is defined as the ratio of metabolic rate during a specific physical activity to a reference metabolic rate.

Insurance

Plan for large number of people who are subject to the same loss and agree to have an insurer assess a premium. Covers cost from pooled resources.

POS

Point of Service

Perspective

Point of view

Negative predictive value

Portion of clients also referred to as enrollees or members in an health insurance plan who are predicted to experience local services that turn out to be truly low cost

Positive predictive value

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

Rehabilitation counselor

Possesses a specialized knowledge skills and then to need it to collaborate in a professional relationship with persons with disabilities to empower them to achieve their goals social personal psychological and vocational

PAC

Post Acute care

Post acute care

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 setting this man" care facilities, long-term care, home care services, rehabilitation and set up acute care facilities, pallets of care or hospice, as well as residential, group homes or assisted living facilities.

Comorbidity

Pre existing condition usually chronicThat because of its presence with a specific condition causes an increase in the length of stay by one day and 75% of the clients

Pre-acute care

Pre-acute care delivery systems focus on health maintenance and prevention both primary and secondary illness or unnecessary progression/deterioration in a clients health condition. Usually requires the least complex and least costly services. Pre-acute care setting is medical clinic or outpatient treatment centers, community care, educational and health maintenance environments or Payor organization.

Global fee

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

Statue of limitation

Prescribing limitations to the right of action on certain describe causes of action, that is, declaring that no suit shall be maintained on such causes of action unless brought with in a specified period of time after the right occurred

Care continuum alliance

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

Benefits

Principal term the type of health and human services covered by insurance/health plan and agreed-upon between the plan and insurance/the individual.

Subpoena

Process commanding a witness to appear and give testimony in court

Planned risk stratification

Process in which case managers a sign clients to risk groups before the client has the need to access a healthcare program or practice setting. Accurately assess their needs and appropriately plan for their necessary care of services.

Work conditioning

Program that uses strengthening and conditioning techniques to enable a worker who has sustained a job related injury or illness to regain function. The program consist of intensive job related and goal orientated treatments specifically designed to restore a workers capacity to perform work task and duties in the environment they are intended to occur.

Special education

Programs that address the needs of students with mental, emotional, or physical disabilities.

PMI

Project Management Institute

Occupational health

Protection, promotion, and maintenance Of the safety health and welfare of individuals and work or employment settings. Focuses on the physical mental emotional and social well-being of workers in all occupations by preventing departures from Health controlling rift and adaptation to the working environment.

Ticket to work program

Provides most people receiving Social Security benefits more choices for receding employment services. This program the Social Security Administration issues tickets to eligible individuals who intern may choose to assign those tickets to an employment network of their choice to obtain employment services, vocational rehab billet Tatian services or other support services necessary to achieve a vocational goal. The employment network if they except the ticket will coordinate and provide appropriate services to help the individual find and maintain employment

National Quality Measures Clearinghouse

Public resource for evidence-based quality measure and measure stats. Sponsored by the department of health and human services. Sponsor through its affiliate the agency for healthcare research and quality (AHRQ)

Competence

Qualified and capable of performing a task

Case rates

Rate of reimbursement that package is pricing for a certain category of services.

Reasonable and prudent

Reasonable refers to a situation in which one exercise a sound Jasmine and ask in a judicious and rational manner. Prudent refers to a situation when an individual is wise and careful and how he or she handles particular matter and exercises common sense.

RAC

Recovery Audit Contractor

RMDG

Reed MD guidelines

Medical disability advisor

Reference that provides disability duration Guidelines, mostly used as a source of accurate data for estimated the potential generation of a disability in there for the time frames of return to work for certain work related diseases or injuries

Qualified rehabilitation provider

Referred to as a qualify rehabilitation counselor, vocational counselor, rehabilitation nurse, or qualify rehabilitation professional.

Return to work with accommodations

Return to gainful employment assuming modified job responsibilities or expectations. Modifications reflect accommodations of the workers limitations based on the outcome of the job related injury or illness. These modifications usually relate to the set of job duties task or responsibilities worker schedule physical demand and type of equipment or to applied.

FIM

Referred to today as FIM[TM] instrument, it is 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[trademark sign] 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[trademark sign] 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[trademark sign] instrument is also used to assess a client's cognitive abilities such as comprehension, expression, social interaction, problem solving, and memory. The typical people in a medical rehabilitation setting who complete the FIM instrument and assign scores to a client include physical therapists, occupational therapists, nurses, psychologists and social workers. This instrument is copyrighted and maintained by the Uniform Data System for Medical Rehabilitation (UDSMR), which is a division of the University of Buffalo Foundation Activities, Inc (UBFA), the not- for-profit corporation that developed and owns the FIM[trademark sign] instrument. (Medfriendly, 2010)

Panel of providers

Refers to healthcare providers including physicians who are responsible for providing care and services to the enrollee and he managed care organization. The providers delivered here to the members based on a contract with the manage care organization.

Mental retardation

Refers to significantly sub average general intellectual functioning manifested during development. And existing concurrently with impairment in adaptive behavior

Communication skills

Refers to the many ways of transferring data from one person to another through the commonly use Media of speech written words or bodily gestures.

RIC

Rehabilitation impairment categories

Outcomes monitoring

Repeated measurements overtime of Alcom indicators in a manner that permits casual inferences about what client characteristics, care processes, and resources produce the observed client outcome

Mandatory outcomes report

Report that consist of outcomes measures require by accreditation agencies.

Voluntary outcomes report

Reports that consist of outcomes measures decided upon by the healthcare provider organization and off they use internally for productivity and performance measurements or improvement opportunities. Examples are revenue and loss statements, cost per case, reimbursement to Niles, barriers to care, and client list staff satisfaction.

Accident year experience

Represents accidents that occur within a given 12 month period and the premiums and during that time

Calendar year experience

Represents losses incurred in premiums are not within a given 12 month.

Policy year experience

Represents the premiums and losses on all policies that going to affect within a given 12 month.

Rehabilitation impairment categories

Represents the primary cause of the rehabilitation stay. They are clinically homogeneous grouping that are been subdivided into case mix groups

Claim

Request for payment Reparation for a loss covered by an insurance contract

HIPPA Privacy Rule

Requires an accounting of all disclosures of PHI information

Medical outcome study short form 36

Research instrument used to measure and individuals perception of his/her own health status and quality of life

Rehabilitation

Restoration a form of function following an illness or injury. Restoration of an individual's capabilities to achieve the fullest possible life compatible with abilities and disabilities. The development of a person to the fullest physical psychosocial vocational and educational potential.

Outcome

Result and consequences of a healthcare process. A good outcome is a result that achieves expected goal. May be the result of Care received or not received. Represents the cumulative effects of one or more processes on a member at pay the five point in time

Return to work full duty

Return to gainful employment in full work capacity with complete responsibilities for all the work duties assumed at the time the worker sustained a job related injury or illness

SSA

Social Security Act

SS

Social support

Plausibility

Something that have the appearance of being true but which actually might be deceptive. Examining plausibility is necessary for determining whether observed change is direct result of applied intervention

Outlier

Something that is a difficult late will above or below and expected range or level.

Catastrophic case management

Specialized and intricate services reflective of the needs of the individual with complex and life-threatening condition. Often catastrophic case management includes a full spectrum of services for the individual or work with a catastrophic injury or illness sometimes including both disability case management and life care planning.

Target utilization rates

Specific goals regarding the use of medical services usually included risk sharing arrangements between managed-care organizations and healthcare providers.

Group model HMO

The HMO contract with a group of physicians for septi per client to provide many different health services in a central location. The group of physicians determines the compensation of each individual physician after sharing profits.

TJC

The Joint Commission

PSDA

The Patient Self-Determination Act 1991

Access to care

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

Emotional intelligence

The ability to perceive, understand, manage, and use emotions

Internal bench marking

The act of comparing or evaluating the current performance of an organization or program against its past performance and improvement standards or targets.

Advocacy

The act of recommending pleading the cause of another. To speak or write in favor of CMSA standards of Practice, 2010

Acute Care

The acute care delivery systems focus on treating sudden and acute episodes of illness such as medical and surgical management or emergency treatment which otherwise cannot be taken care of in a less intense care setting. Acute care settings may include hospitals, acute rehabilitation centers, emergency care, transitional hospitals and follow up long term disease management settings.

case law

The aggregate of reported cases for me a body of jurisprudence, or law of a particular subject as evidence or form by the adjudged cases in distinction to statues and other sources of law

Approval charge

The amount Medicare pays a physician based on the Medicare fee schedule. Physician may bill the beneficiaries for the additional amount, subject to the limiting charge allowed.

Rating

The application of the proper classification rate and possibly other factors to set the amount of premium for a policyholder. The three principal forms of writing our manual rating, experience Rating, and retrospective rating

Certifications

The approval of a client care services, admission, or length of stay by health benefit plan based on information provided by the healthcare provider.

Authorization

The approval of client care services,admission or length of stay by a health benefit plan based on information provided by the healthcare provider.

Administrative Law

The 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

Rate

The charge per unit of payroll which is used to determine Worker's Compensation or other insurance premiums. The rate varies according to the risk classification within which the policyholder my fall.

Principal diagnosis

The chief complaint or health condition that requires the clients admission to the hospital for care.

algorithm (n)

The chronological delineation of steps in or activities of clients care to be applied in the care of clients as they relate to specific conditions/situations.

Disengagement

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

Vocational evaluation

The comprehensive assessment of vocational aptitude and potential use the information about a person's past history medical and psychological status and information from appropriate vocational testing which may use paper and pencil instruments work samples simulated workstation or assessment in a real work environment.

Case management process

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. The steps and close creamy assessing stratifying the risk planning implementing follow up transitioning post transitioning communication and evaluating outcomes. The process with special intervention by case managers work together with clients to evaluate and understand the care options available.

Care coordination hub

The context of delivering integrated Health care services to clients, support system with special emphasis on collaboration, coordination and communication among multiple healthcare providers, Care settings and agencies in an attempt to assure client safety and the provision of quality cost effective case management services.

Health and human services continuum

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 spiritual care and services across one Or more care settings.

Health Policy

The course of action to address a Health Care issue or concern by the community at-large or specific groups within the community. The process involves the interplay of numerous individuals and interest groups collaborating to influence health policy makers to act in a particular way.

Public policy

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 in collaborating to influence policy makers to act in a particular way.

Intake

The decision in a case manager makes about the provision of case management services to a client. Collection of current health problems medical and social history psychosocial dynamics treatment plan rest that is another

Care coordination

The deliberate organization of patient care activities between two or more involved in patient care to facilitate the appropriate delivery of healthcare services.

Universal design

The design of products and environment to be usable by all people to the greatest extent possible without the need for adaptation or specialize design

Case reserve

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

Burden of proof

The duty of producing evidence as the case progresses and or the duty to establish the truth of a claim by Preponderance of the evidence

Adaptive behavior

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

Fidelity

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

Vocational rehabilitation

The evaluation and training aimed at assisting a person to enter or reenter the labor force

adherence

The extent to which a persons behavior-taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider.

Effectiveness of care

The extent to which care is provided correctly i.e. to meet the clients needs, improve quality of care, and with all the clients problems, given the current state of knowledge, and the desire outcome is achieved

Efficiency of care

The extent to which care provided to meet the desire sex/outcomes to improve quality of care and prevent the use of unnecessary resources.

Rehabilitation engineering

The field of technology and engineering serving disabled individuals in their rehabilitation. Includes the construction and use of great variety of devices in instruments decide to restore or replace function mostly of the locomotion and sensory systems.

Evaluating outcomes

The final step of the case management process which is achieved by measuring the results and consequences of the case management services provided to a client and their support.

Direct examination

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

Appeal (care provision related)

The formal process or request to reconsider a decision made not to approve an admission or healthcare services, reimbursement for services rendered or a clients request for postponing the discharge date and extending the length of stay.

Utilization

The frequency which a benefit issues during a one year. Usually expressed in occurrences per 1000 covered lives

Utilization of health benefits

The frequency with which a benefit issues during a one year. Use express in occurrences per 1000 covert lives

Carrier

The insurance company or the one who agrees to pay for the losses. A carrier may be organized as a company either Stack mutual or reciprocal or as an association or underwriters.

Insurer

The insurance company that provides planned protection against economic losses

Level of care

The intensity and effort of health and human services and care activities required to diagnose, treat, preserve or maintain a member health. Level of care can vary from least to most complex, least to most intense, or prevention and wellness to acute care and services.

Cross examination

The interrogation of a witness by the opposing party

Remedy

The means by which a right is enforced or the violation of the right is prevented readdressed or compensated

Vocational testing

The measurement of vocational interest aptitude and ability using standardized professionally accepted psychomotor procedures

Legal reserve

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

Transition

The movement clients make between healthcare providers and said he was due to a change in their clinical condition needs and or intervention.

Length of stay

The number of days that A health plan stay in an inpatient facility , home health or hospice.

Affect

The observable emotional condition of an any given time

Loss Ratio

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

Peritransition

The period that surrounds a client transition before during and after transition

Complainant (Plaintiff)

The person or entity bringing or filing

Payor representative

The person or organization representing the Payor (health insurance agency). Able to speak and make decisions on behalf of the Payor and could be Case Manager, Doctor, Medical advisor, claims manager and Quality management specialist.

Payor

The person who writes the check to another. Responsible for funding

Insured

The person, organization or other entity who purchase insurance

Maximum medical improvement

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 improvement are considered unlikely despite continued care and treatment.

Primary care

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

Efficacy of care

The potential, capacity or capability to produce the desired effect for outcome as already shown, i.e. through scientific Research findings.

Disenrollment

The procedure of dismissing individuals or groups from their enrollment with a health care carrier

Three point contact

The three main person a Worker's Compensation case manager contact upon getting engaged in a workers case. These include the injured or ill worker, the workers employer, and the workers treating physician .

Short term disability income insurance

The provision to pay benefits to a covert disabled person as long as he remains disable up to a specific period not exceeding two years.

Health Care trilogy

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

Medical loss ratio

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

Value

The relative worth of something including merit, importance monetary return impact on others for things or contribution towards achieving a goal or purpose. It is also referred to as individuals personal interest desires or beliefs

Premature discharge

The release of a client from care before he or she is deemed medically stable and ready for terminating treatment/care

Payer

The responsible party for reimbursement of healthcare. Such as Center for Medicare and Medicaid and managed care organizations

Partial disability

The result of an illness or injury which prevents any shorts from performing one or more of the function of his or her regular job.

Right of privacy

The right of an individual to withhold his or her personalFrom Publix Crowely is still desire as long as it is consistent with the law or public policy.

SUBROGATION

The right to pursue and lean upon claims for medical charges against another person or entity.

Risk management

The science of the identification, evaluation, and treatment of actual or potential financial or clinical losses. Usually occurs through a formal program that attempt to avoid, prevent or minimize negative result. The program consists of a comprehensive set of activities that aim to identify, evaluate and take corrective action against risk that may lead to clients or staff injury with resulting financial loss or legal liability.

Diffusion of innovation

The spread of new technologies, ideas, or ways of doing things in a particular culture. What is the process of communicating change for the purpose of increasing the rate of its adoption and acceptance.

Privacy

The state or condition of having the freedom from unauthorized or undo intrusion observation and disturbance and once private life and affairs including unwanted disclosure of one person information, health condition, and health services.

Implementing

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

Following up

The step of this management process with case managers with you, evaluate, monitor every assess the clients health condition, needs, ability to care for self, knowledge of health condition and case management plan of care, outcome of the implemented treatments and interventions, and continue to progress of the plan of care.

Case Mix Index

The sum of DRG relative weight of all patient seen during the one year in an organization divided by the number of cases hospitalized and treated during them the same year.

Benefit package

The sum of services for which a health plan government agency or employer contracts to provide. In addition to basic physician and hospital services some plans also cover prescriptions dental and vision care.

Assurance/Insurance

The term assurance is used more commonly in Canada/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.

Community Skills

Those abilities needed to function independently in the community. They may include telephone skills, money management use of public transportation meal planning and cooking.

Non-maleficence

To do no harm

Approval

To offer or receive affirmation, sanction, or agreement about a decision, action service treatment or intervention. In the health insurance, it is the act of authorizing or affirming a service to the 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.

Minimum data set

Tools used in skilled nursing facilities to place patients into resource utilization groups which determine the facilities reimbursement rate

Outlier threshold

Upper range Bradshaw in the Thursday before a client stay in a hospital becomes an outlier. It's the maximum number of days a client may stay in the hospital for the same fix the reimbursement rate. The outlier threshold is determined by the centers for Medicare and Medicaid services.

Outcomes management

Use of information in knowledge gained from outcome monitoring to achieve optimal outcomes through improve clinical decision-making and service delivery.

Medical necessary

Used to describe the supplies and services provided to diagnose and treat a medical condition in accordance with nationally recognized standards

appropriateness of setting

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

Delay in service

Used to identify delays in the delivery of need it services and to facilitate and expedite Such services when necessary

Utilization of resources

Using establish criteria as a guide determination is made as to whether the client is receiving all of the appropriate services

Under utilization

Using establish criteria as a guide the termination with made as to whether the patient is receiving all of the appropriate services

Overutilization

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

UM

Utilization Management

URAC

Utilization Review Accreditation Commission

VRS

Vocational rehabilitation specialist

Permanent and stationary

When the condition of the 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 workers condition. This point signals the end of temporary disability benefits and the need to examine the likelihood of permanent Benefit is there.

Body of knowledge

Widely recognize information standard methods tools and practices about a specific field. Prescribed aggregation Of essential knowledge in a particular field or specialty.

Permanent total disability

Workers 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.

Disclosure

Written authorization regarding the sharing of the clients information

Individualized plan for employment

Written plan that outlines and individuals vocational goal and the services to be provided to reach the goal. It formulizes the planning process through which the vocational goal, service delivery, and time frames for service delivery are determined. Also identify the individuals employment objective unique strengths priorities concern and capabilities.

Reprimand

Written statement indicating that a board-certified case managers actions or in actions have been found, after careful review, to barley the cold and want to more ways, and that the consequences either have or could have resulted in substantial harm to a client for public. Usually a reprimand is triggered by a new review conduct conduct i written statement indicating that a board-certified case managers actions or in actions have been found, after careful review, to Violate the code in more ways, and that the consequences either have or could have resulted in substantial harm to a client or public. Usually a reprimand is triggered by a review conducted because of a complaint about to CCMC by concern party about the board certified case manager.

Life care planning

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 ultimate goal to promote and maintain good health safety and wellbeing and quality of life

Claimant (n)

a person making a claim

Caregiver

a person that provides care for and meets the needs of someone else

Risk stratification

a tool for identifying and predicting which patients are high risk

Social networking

a website where one connects with those sharing personal or professional interests

literacy

ability to read and write

Premium

an amount to be paid for an insurance policy.

sentinel event

an unexpected occurrence involving death or serious physical or psychological injury

Assistive Technology

any item or equipment used to improve the functioning of a disabled person

Custodial care

assistance with the activities of daily living; also called personal care

Impeach

call into question the integrity or validity of (a practice).

Medical Home model

care focus on primary provider care and relationship between patient, family, and physician

CPR

computerized patient record

First level reviews

conducted while the patient is in the hospital, care is review for appropriateness

CQI

continuous quality improvement

Intermediate outcome

desired outcome that is Met during a clients hospital stay. It's a milestone in the care of a client or a trigger point for advancement in the plan of care.

EHR

electronic health record

EPR

electronic patient record

Independent medical examination

examination conducted by a physician to confirm that an individuals is permanently disabled. Also assisted in a timely whether a worker has reached the maximum benefit for treatment and whether any permanent impairment remains after treatment.

FFS

fee for service

case conferences

focused opportunities to present information to or about clients. Multidisciplinary healthcare team meetings.

FCE

functional capacity evaluation

FIM

functional independence measurement

handicapped

having a physical or mental disability

Chronic illness

health condition that last longer than three months

LOS

length of stay

MMSE

mini mental status examination

MDS

minimum data set

NPV

negative predictive value

network model HMO

one that contracts with more than one medical group practice

Patient self-determination act 1991

patients right to specify if they want to except or a few specific medical care and identify a legal representative for urgent healthcare decision purposes.

PMPM

per member per month

Principal procedure

performed for definitve treatment rather than diagnostic purposes

P&S

permanent and stationary

Medicare Part B covers

physician outpatient medical services, diagnostic tests

PPO

preferred provider organization

POA

present on admission

never events

preventable errors

QOL

quality of life

Motion

request to the court to take some action or to request the opposing side to take some action relating to a case

RUG

resource utilization group

Retrospective review

review done after the patient has received care and discharged

Integrated delivery system

single group of organizations that provide care across a continuum of settings

SNF

skilled nursing facility

Compensation

something, typically money, awarded to someone as a recompense for loss, injury, or suffering.

TDD

telecommunication device for the deaf

job analysis

the process of getting detailed information about jobs

remand

to send a case back to a lower court to be tried again

assistive device

tool, software, or hardware to assist in performing daily activities

TBI

traumatic brain injury

Complication

unexpected condition that arises during the hospital stay or Health Care in counter that prolongs the length of stay at least one day.

Work Adjustment

use of simulated work activity to develop work behaviors, attitudes, characteristics

collaboration (n)

when two or more people work together to create or achieve something