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Medica Administrative Manual Home > Glossary of Terms

Glossary of Terms

The glossary of terms is an alphabetical list of all terms within the Medica Provider Administrative Manual.

 

A

Abuse
A pattern of practice that is inconsistent with sound fiscal, business or health service  practices, and that results in unnecessary costs to Medica or in reimbursement for services not medically necessary, or that fails to meet professionally recognized standards for health services.

Accessibility
The ease with which an eligible member may obtain available services through a managed care organization.

Accreditation
One form of external review. In the realm of health care, accreditation generally means that a delivery system has met certain established standards that represent an acceptable level of performance. Accreditation of a health care system is considered by many to be a seal of approval on which purchasers and consumers can base decisions.

Adjustment
A method to correct claim reimbursement processing errors, or to incorporate late credits/charges.

Administrative Cost
Costs incurred by a carrier, such as an insurance company or HMO, for administrative services such as claim processing, billing, enrollment and overhead.

Admission
The admittance of a member to a hospital, skilled nursing facility or licensed acute care facility for a period of not less than 24 hours.

Agreement
The signed Medica Participation Agreement, including any addenda, appendices, exhibits and attachments, the Medica Administrative Manual, the Credentialing Plan and the provider’s application for participation constitute the entire agreement between Medica and the provider. All such individual elements of the agreement are subject to amendment as provided in the Medica Participation Agreement.

Alternative Care
Home health care, home IV therapy or other medical services arranged as an alternative to, or in lieu of, hospital inpatient care or outpatient facility care.

Appropriateness
Measures whether or not a particular provided service is indicated in the care of a given patient or whether a needed service has not been provided. Of particular importance are diagnostic procedures, medications and therapeutic procedures.

Availability
The degree to which the appropriate care/intervention is available to meet the needs of the member.

Average Length of Stay (ALOS)
Average number of days in a hospital for each admission.


B

Benefit Document
A plan of health care coverage, issued by Medica for each Medica product, that contains the terms and conditions of a member’s coverage. Also referred to as a “benefit plan” with self-insured plans.


C

CMS
See Centers for Medicare & Medicaid Services.

CMS-1500 (formerly HCFA-1500)
A universal form for health care providers to submit claims to health carriers.

Capitation
A type of risk-sharing reimbursement method whereby providers in a health plan’s network receive fixed periodic reimbursements (usually monthly) for health services rendered to plan members. Capitated fees are set by contract between a health plan and health care
providers to be reimbursed on a per-person basis, usually with adjustments for age, sex and family size, regardless of the amount of services rendered or costs incurred. The health plan may set aside a percentage of the total annual capitation reimbursement in a
risk pool to safeguard against unexpected costs. At the end of the year, any money left in the risk pool is returned to the providers.

Care Coordination
Coordination of all health care, dental care and social needs for a Medica DUAL Solution™ (MSHO demonstration product) member.

Care Management
Review and management of health services to determine that they are medically appropriate for members’ needs.

Care System
An entity that Medica contracts with at full risk to provide for and coordinate all health care needs for a member enrolled in Medica DUAL Solution™.

Carrier
An organization that has entered into a contract with the Centers for Medicare & Medicaid Services (CMS) to process Medicare claims for physicians’ services, outpatient hospital services, durable medical equipment, and services and supplies not covered by the hospital insurance (Part A) of Medicare.

Case Management
Methodology used to ensure that the highest quality, most efficient care is provided to members and across a continuum of care, services and time.

Centers for Medicare & Medicaid Services (CMS)
The federal agency responsible for administering Medicare and overseeing states’ administration of Medicaid.

Child & Teen Checkups (C&TC)
The name of Minnesota’s Early Periodic Screening, Diagnosis and Treatment (EPSDT) Program. EPSDT is a federally mandated program to provide comprehensive screenings to Medicaid recipients under age 21. Medica is required to provide C&TC screenings to its Medica Choice Care and Medica MinnesotaCare members through its contract with the Minnesota Department of Human Services. C&TC screenings include physical and oral exams, vision and hearing evaluations, developmental screenings and immunizations.

Childhood Asthma Program
A referral program consisting of three to six home health care visits by a registered nurse to educate pediatric asthma members and their families about triggers, appropriate medication, peak flow meter use and self-management of the disease.

Claim
An invoice, bill or itemized statement for services provided to a member.

Clinical Practice Guidelines
Systematically developed statements to assist providers and members with appropriate health care decisions for specific clinical circumstances.

Clinical Quality
Clinical quality has two components:

  1. Technical: The skill and competence of people, and the systems, procedures and equipment that perform reliably and effectively in a way that is quantifiable.
  2. Experiential: The subjective experience of the healing relationship that is developed through the member’s interactions with the provider and the environment in which care and services are provided.

Complaint
A verbal or written expression of dissatisfaction by a member or participating provider.

Consultation
A circumscribed diagnostic or management opinion requested of a specialist physician by another physician. It includes the implicit or explicit expectation that care will be returned to the referring physician after the consultation is completed.

Continuity of Care
If Medica terminates its contract with a provider without cause, or if a member’s employer changes health plans and the member’s current provider is not a network provider, the member may be able to continue care with that provider and be eligible for in-network benefits.

Coordination of Benefits (COB)
A provision applicable when a member is covered under more than one health plan. It requires coordination of the reimbursement of benefits by all plans to eliminate overinsurance or duplication of benefits.

Copayment or Coinsurance
The amount a member is required to pay for certain health services in accordance with the member’s benefit document.

Cosmetic
Services and procedures that improve physical appearance but do not correct or improve a physiological function and are not determined to be medically necessary.

Credentialing
The process focused on verification of adequate training, experience, licensure and competence, and the assessment of the data and information collected to determine if an individual or organizational provider is qualified and competent to render acceptable quality
of care to Medica members. The credentialing process with qualification criteria is set forth in the Credentialing Plan established by the Medica board of directors. All actions related to acceptance, denial, discipline and termination of participation status of a provider are governed by the Credentialing Plan. The board has ultimate responsibility and authority for all credentialing actions.

Credentialing Subcommittee
Reviews providers’ compliance with the professional criteria of the Credentialing Plan. Makes decisions regarding acceptance and/or continuance as a Medica participating provider.

Current Procedural Terminology (CPT-4)
A listing of descriptive terms and identifying codes for reporting medical services and procedures.

Customary Charge
The usual fees charged by a health care provider.

Customers
Parties who receive and pay for services. These include consumers, employer purchasers and public sector purchasers.

 

D

Deductible
The annual amount of charges for health services, as provided in the member’s benefit document, that the member is required to pay in advance of any coverage by Medica.

Diagnosis-related Group (DRG)
A system of classification for inpatient hospital services based on principal diagnosis, secondary diagnosis, surgical procedures, age, gender and presence of complications. This system of classification is used as a financing mechanism to reimburse hospitals and other selected health care providers for services rendered.

Discharge Planning
The evaluation of patients’ medical needs in order to arrange for appropriate care after discharge from an inpatient setting.

Drug Enforcement Administration (DEA)
The federal agency that issues licenses to prescribe and dispense scheduled drugs.

Drug Formulary
A list of medications covered for Medica members. Content is determined by Medica’s Pharmacy and Therapeutics Committee, and is based on safety, efficacy and cost. The formulary is reviewed on a regular basis to ensure it remains responsive to the therapeutic needs of members and participating providers.
Go to Medica List of Preferred Drugs (Formulary).

Durable Medical Equipment (DME)
Medical equipment that can stand repeated use and is generally used at home.


E

Effectiveness
The degree to which care/intervention is provided in the correct manner, given the current state of knowledge, in order to achieve the desired outcome(s) for the member. The effectiveness of health care relates to professional and support staffs’ ability to perform in a manner that ensures members achieve the most desirable outcomes. Effectiveness involves minimizing risks to members and documenting members’ health status and the care provided.

Efficiency
The ratio of outcomes (results of care/intervention) for a member to the resources used to deliver the care.

Elderly Waiver Services
Services that are covered under an MSHO program (Medica DUAL Solution™) that would normally be considered “custodial” in nature. Examples include meals on wheels, adult day care and foster care.

Elderly Waiver Vendor
A person/entity who (a) if required is duly licensed, registered or certified in Minnesota, (b) provides goods or services that constitute Elderly Waiver Services, and, (c) is a partner or shareholder in, employed by or under contract with a care system.

Electronically Stored Data
Data stored in a typewriter, word processor, computer, existing or pre-existing computer system or computer network, magnetic tape or computer disk.

Eligible Expense
The customary charge for health services covered under the member’s benefit document.

Emergency
A condition for which a reasonable layperson believes the circumstances require immediate medical care that could not wait until the next working day or next available clinic appointment. A condition that requires immediate treatment to preserve life; prevent serious impairment to bodily functions, organs or parts; or prevent placing physical or mental health in serious jeopardy.

Evaluation
The review and assessment of the quality and appropriateness of an important aspect of care for which a pre-established level of performance (threshold for evaluation) has been reached during monitoring of activities.

Explanation of Benefits (EOB)
A statement sent to members by Medica listing services provided, amount billed, copayment, coinsurance or deductible, and reimbursement made.


F

Facility
An entity that provides diagnostic, medical, therapeutic and/or surgical services by or under the direction of physicians and with continuous RN services. This includes but is not limited to hospitals, ambulatory surgical centers and skilled nursing facilities.

Fee-for-service
The payment to health care providers for service(s) rendered.

Fee Maximum
The maximum fees reimbursable for health services rendered by a participating provider and determined from time to time by Medica. Such fees generally vary for each of the Medica products and may vary to reflect unique characteristics of certain health services.

Fee Schedule
A schedule of fee maximums developed by Medica for the purpose of establishing common reimbursement amounts made to participating providers for certain products, procedures and services.

Financial Records
Includes written and electronically stored data of a provider who receives payment for a member’s service from Medica.

Foreign Language Interpreter Service
A service to help Medica Choice Care, Medica DUAL Solution™ and Medica MinnesotaCare members gain better access to health care. Medica arranges for foreign language interpreter services during office visits with participating providers, at no cost to members.

Fraud
Any acts that constitute a crime against Medica or other health care programs, or attempts or conspiracies to commit those crimes.

Function
Goal-directed, interrelated series of processes, such as quality assessment and improvement functions.


G

Gatekeeper
A designated physician or clinic that provides or coordinates all health care services for a member.


H

HCFA
See Centers for Medicare & Medicaid Services.

HCFA-1500
See CMS-1500.

Health Care Common Procedure Coding System (HCPCS)
A listing of codes and descriptive terminology used for reporting the provision of supplies, materials, injectable drugs and certain medical services to payers, developed by CMS.

Health Maintenance Organization (HMO)
An entity that provides, offers or arranges for coverage of designated health services needed by health plan members for a fixed, prepaid premium.

Health Plan Employer Data and Information Set (HEDIS)
HEDIS was designed to permit employers to understand what value their health care dollars buy and provide the information necessary to hold a health plan accountable for its performance. HEDIS includes health plan performance measures in quality, access, utilization, satisfaction and finance.

Health Profile
A health assessment tool to gather information on members newly enrolled in a Medica health plan. The assessment focuses on four topics:

  • Access to health services.
  • Current health needs of the member.
  • General health history of the member, including family medical history.
  • Preventive behavior.

Health Records
Any electronically or written stored data, and written or diagrammed documentation of the nature, extent and medical necessity of a health service provided to a Medica member.

Health Services
The health care services and supplies provided to a member and covered under the member’s benefit document.

Home Health Care Agency
A facility licensed, certified or otherwise authorized, pursuant to state and federal laws, to provide health care services in the home.

Hospice
A facility or program licensed, certified or otherwise authorized, pursuant to the law of jurisdiction in which services are received, to provide palliative and supportive care to the terminally ill.

Hospital
A facility that provides diagnostic, medical, therapeutic and surgical services by, or under, the direction of physicians and with 24-hour RN services.

Hospital Contingency Reserve (HCR)
A fund consisting of amounts deducted from sums otherwise reimbursable to a hospital that are subject to withholding by Medica in Medica’s sole discretion and earned and, as applicable, paid out in the event certain performance standards are met. The amount of HCR withheld and the conditions for earning and pay-out with respect to each Medica product are described in more detail in the appendices to the Medica Participation Agreement.

 

I

Identification Card
Issued to members by Medica, this card contains member’s name and number, and identification of member’s specific benefit document. When applicable, also indentifies member’s primary care clinic.

Improvement Plan
The recommendation(s) for action that is made following analysis of study findings.

Indicator
A quantitative value that reflects the condition and direction over time of a specified process or outcome.

International Classification of Diseases, 9th Ed., Clinical Modification (ICD-9-CM)
A numerical coding system for classifying diseases and operations that is used to identify patient diagnoses linked to physician services by payers and insurers.


J

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
A private, not-for-profit organization that evaluates and accredits hospitals and other health care organizations providing home care, mental health care, ambulatory care and long-term care.


L

Length of Stay (LOS)
The number of days a member stayed in an inpatient facility.


M

MSHO
See Minnesota Senior Health Options.

Managed Care Organization (MCO)
A system of health care delivery that influences utilization and cost of services and also measures performance. The goal is to achieve a system that delivers value by giving members access to quality, cost-effective health care.

Medica
In this manual, unless otherwise stated, all references to Medica include Medica-(MN), MIC, MHPW and MSI, defined as follows. Medica-(MN) is a health maintenance organization organized pursuant to the laws of the State of Minnesota. Medica Insurance Company (MIC) is a stock insurance company organized pursuant to the laws of the State of Minnesota. Medica Health Plans of Wisconsin (MHPW) is a health maintenance organization organized pursuant to the insurance laws of Wisconsin. Medica Self-Insured (MSI) is a Minnesota nonprofit corporation.

Medicaid
A federally aided, and state-operated and administered program that provides certain health care benefits to eligible low-income people. This program is referred to as Medical Assistance (MA). Medica Choice Care is the product designed for Medicaid recipients.

Medical Policy Committee (MPC)
Advises Medica on matters of medical appropriateness regarding utilization review, prior authorization utilization management policies and clinical guidelines. The MPC is composed of appointed, board-certified, practicing physicians in family practice, internal medicine, obstetrics and gynecology, and pediatrics, as well as a consumer representative.

Medical Policy Manual
A clinical reference that contains utilization management policies, clinical guidelines and medical technology policies. Learn more about Medical Policies and Clinical Guidelines.

Medical Record
The record in which clinical information related to the provision of physical, social and mental health services is documented.

Medical Trend
The year-to-year increase or inflation in medical costs.

Medically Necessary
Diagnostic testing, preventive services and medical treatment consistent with the diagnosis of a prescribed course of treatment for a member’s condition, which Medica determines on a case-by-case basis according to the:

  • Consistency with medical standards and accepted practice parameters of the community as determined by health care providers in the same or similar general specialty and considered appropriate for the member’s condition.
  • Ability to help restore or maintain a member’s health.
  • Ability to prevent deterioration of a member’s condition.
  • Ability to prevent the likely onset of a health problem or detect an incipient problem.
  • Nonexclusion from the member’s benefit document.

The fact that a provider has performed, prescribed or recommended a service, or that a service is the only available treatment, may not mean the service is medically necessary and a covered benefit.

Medicare
A program administered by the Social Security Administration that covers the medical care of individuals over age 65 and certain qualified persons under age 65.

Medicare Approved Amount
The portion of Medicare eligible expenses for health services allowed and reimbursed by Medicare.

Medicare Coinsurance
The percentage charge of the Medicare eligible expenses not reimbursed by Medicare.

Medicare Contract
A contract entered into between Medica and CMS that governs the arrangement Medica has with participating providers regarding the provision of health services to Medica Select Solution™ and Medica Prime Solution™ members.

Medicare Deductible
The dollar charge of the Medicare eligible expenses not paid by Medicare.

Medicare Eligible Expense
The customary charge for health services provided to Medica Select Solution™ and Medica Prime Solution™ members to the extent recognized by Medicare as reasonable and medically necessary. Non-Medicare eligible expenses are those health care expenses not covered by Medicare.

Medicare Part A
Funds created under the Social Security Act to provide hospital insurance coverage to Medicare beneficiaries, including inpatient services and supplies.

Medicare Part B
Funds created under the Social Security Act to provide supplementary medical insurance to Medicare beneficiaries for various nonhospital services, including physician’s services, outpatient hospital care and some medical supplies.

MedImpact
The company Medica contracts with to coordinate pharmaceutical services to Medica members.

Member
An individual properly enrolled for coverage under a benefit document. Also referred to as a “covered person” in self-insured plans. Member Identification Number The 16-digit number that identifies a patient as a Medica member. The member number consists of a member’s group number, an identification number (typically the subscriber’s social security number) and a two-digit family number.

Minnesota Department of Commerce (MDOC)
The state government agency responsible for regulation and licensing of insurance companies.

Minnesota Department of Health (MDH)
The state government agency responsible for regulation of health care delivery, including licensing and regulation of HMOs.

Minnesota Department of Human Services (MDHS)
The state government agency responsible for administration of General Assistance Medical Care (GAMC) and Medicaid.

Minnesota Senior Health Options (MSHO)
A demonstration project by the Minnesota Department of Human Services that creates an alternative delivery system for acute and long-term care services and integrates Medicare and Medicaid funding for persons age 65 and over who are eligible for Medicare and Medicaid. Medica DUAL Solution™ is Medica’s MSHO health plan.

Modifier
A two-digit suffix code that allows reporting of an altered service or procedure without changing the definition of the procedure code. Monitoring Activity The collection of information relating to quality of care. Monitoring activities may be prospective, concurrent or retrospective audits; reports; surveys; observations; interviews; complaints; peer reviews; or focused studies.


N

National Committee for Quality Assurance (NCQA)
A nonprofit organization that seeks to improve patient care and health plan performance in partnership with managed care plans, purchasers, consumers and the public sector. NCQA evaluates health plans’ internal quality processes through accreditation reviews and works to develop health plan performance measures.

Net Service Fee Revenue (NSFR)
The MSHO capitation received by Medica less Minnesota Comprehensive Health Associate tax assessed on the Medicare Capitation, the MA surcharge and the one percent premium tax.

Nonparticipating Provider (a.k.a. Nonnetwork Provider)
A health care provider who is appropriately licensed in the state or states where the provider renders health services, but has not contracted with Medica to be a participating provider.

Nursing Home Certifiable
A designation indicating, based on the pre-admission screening (PAS), that a Medicare enrollee is in need of nursing facility level of care, but has decided to remain living in the community.

 

O

OPTUM®
A program designed to help members manage personal problems. OPTUM works in coordination with Medica when a member needs assistance with legal issues, financial concerns, family problems, workplace stress or mental health/substance abuse issues.

Outcome Criteria
Elements for evaluating end results in terms of health and satisfaction.


P

PMAP
See Prepaid Medical Assistance Program.

Participating Provider (a.k.a. Network Provider)
A health care provider who is appropriately licensed in the state or states where the provider renders health services and has entered into an agreement with Medica, has been accepted by Medica to provide health services to members, and whose status as participating provider has not been terminated by Medica.

Peer Review Organization (PRO)
An entity established by the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 to review quality of care and appropriateness of admissions, re-admissions and discharges for Medicare patients.

Performance Measurement
A systematic process for assessing what an organization does and achieves across multiple dimensions.

Practice Profiling
Assessment of patterns of health care service delivery and consumption over time. Units of analysis could include individual health care providers, groups of providers by specialty, departments, clinics and defined populations.

Pre-admission Screening (PAS)
The assessment of enrollees for the purposes of preventing or delaying nursing facility placements and to offer cost-effective alternatives appropriate for the enrollees’ needs. They are conducted by the care system in conjunction with a county social worker upon enrollment into the MSHO program, and again as the condition of the enrollee change or annually, whichever happens first.

Preferred Provider Organization (PPO)
A contractual relationship among hospitals, physicians, insurers and third-party administrators by which the network of providers delivers health care services to employers and other purchasers based on a negotiated system of reimbursement using case management to review utilization.

Premium
The monthly amount required to be paid by the employer on behalf of, or for, members.

Prepaid Medical Assistance Program (PMAP)
Includes Medical Assistance (MA) and General Assistance Medical Care (GAMC) health plans.

Prescription Drug
A drug approved by the Food and Drug Administration (FDA) for prescribed use and route of administration.

Primary Care
The first-line health and medical care provided for the diagnosis and treatment of common ailments usually including most preventive, educational and health maintenance services. Primary care is most often provided by family practitioners, general internists, pediatricians and obstetrician/gynecologists who also serve as the primary physician responsible for the overall continuity of care. Primary care also involves guiding members to the most appropriate use of consultative and referral specialist services.

Primary Care Physician (PCP)
A physician whose majority of practice is devoted to internal medicine, family/general practice or pediatrics. An obstetrician/gynecologist also may be considered a primary care physician, depending on the Medica product.

Provider
A generic term used to encompass both participating and nonparticipating health care providers.

Provider Contingency Reserve (PCR)
Amounts deducted and withheld from claims at the time of initial claim reimbursement to participating providers by Medica. The amount of PCR to be returned by Medica to participating providers is determined by the Medica board of directors. The individual clinic PCR return may be based on, but not limited to, plan financial performance and provider performance in the areas of quality, member satisfaction, access to care, and efficient and cost-effective delivery of care.

Provider Directory
A listing of participating providers by specialty and location.

Provider Number
The seven-digit number assigned to every Medica participating provider.


Q

Quality Assessment Complaint Tracking System (QAC)
An automated system designed to track members’ complaints and potential quality issues to identify patterns and trends in quality activities on a physician-specific and clinicspecific basis.

Quality Improvement Subcommittee
A subcommittee of the Medica board of directors that oversees the Quality Improvement Program.


R

Rate Cell
The category attributed to an enrollee to determine the monthly capitation payment. A rate cell is assigned based on rate cell determinants, which may consist of all or a part of the following, consistent with Medicaid Management Information System (MMIS) requirements: county of residence, major program, eligibility type, sex, age, living arrangements, Medicare status and nursing home certifiability.

Recredentialing
The process whereby Medica periodically verifies the status of a participating provider and the provider’s continual satisfaction of credentialing requirements. Recredentialing considers additional information regarding the provider’s performance in Medica, including, but not limited to:

  • Member complaints.
  • Results of quality reviews.
  • Utilization management information.
  • Member satisfaction surveys.
  • Medical record reviews.
  • Results of site visits.
  • Physician Performance Evaluation (PPE) results.

Referral
Authorization process for a member to receive medically necessary health services from a provider outside of the member’s primary care clinic.

Referral Authorizaton Form
A written or electronic document completed by a member’s care system that authorizes a member to receive certain health services.

Regional
An operational term used to define activities outside the Twin Cities metropolitan area.

Restriction
The exclusion or limiting, for a reasonable time, of the scope of health services for which a provider may receive payment from Medica.

Risk Contract
An agreement between the Centers for Medicare & Medicaid Services (CMS) and an HMO or competitive medical plan requiring the HMO to furnish, at a minimum, all Medicarecovered services to Medicare-eligible members for an annually determined, fixed, monthly reimbursement rate from the government and a monthly premium paid by the member. The HMO is then liable for the cost services, regardless of their extent, expense or degree.

 

S

Safety
The degree to which the risk of an intervention and the risk in the care environment are reduced for the member and others, including the health care provider.

Service Area
The geographic area where Medica is licensed or contracted to sell health care products.

Skilled Care
Nursing or rehabilitation services requiring the skills of technical or professional medical personnel to develop, provide and evaluate care and assess a member’s changing condition.

Skilled Nursing Facility (SNF)
A licensed bed or facility (including an extended care facility, hospital swing bed and transitional care unit) that provides skilled transitional care.

Skilled Nursing Facility (SNF) Review
A medical record review for quality concerns in skilled nursing facilities.

Standards
Professionally developed expressions of the range of acceptable variation from a norm or criterion.

Standing Referral
A referral used by a network provider and authorized by Medica for conditions that require ongoing services from a non-network specialist provider. A standing referral will only be authorized for the period of time appropriate to the member’s medical condition.

Study
A generic term used to refer to a quality improvement audit or a monitoring activity.

Sub-capitation
Where the care system capitates a contracted clinic entity.

Suspending Participation or Suspension
Making a provider ineligible for reimbursement by Medica for a stated period of time.

Suspending Payments
Stopping any or all payments for health services billed by a provider pending resolution of the matter in dispute between the provider and Medica.


T

Third-party Administrator (TPA)
An independent, corporate entity responsible for administration of an employer’s group benefit plan(s), claim reimbursement and self-insured programs. A TPA does not underwrite or assume group risk.

Third-party Payer
“A person, entity, agency, or government program…that has a probable obligation to pay all or part of the costs of a recipient’s health services. Examples are an insurance company, health maintenance organization, the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), workers’ compensation, and defendants illegal actions arising out of an accidental or intentional tort” (Minnesota Rules, part 9505.0015, subpart 46).


U

Uniform Billing Code of 1992 (UB-92)
A federal directive requiring a hospital to follow specific billing procedures that itemize all services included and billed on each claim.

United Behavioral Health (UBH)
The mental health and substance abuse services (MH/SA) division of United HealthCare Corporation (UHC) with which Medica has contracted to provide MH/SA services to Medica members.

United HealthCare Corporation (UHC)
The company with which Medica has contracted to provide administrative services.

Urgent Care Center
A health care facility–distinguishable from an affiliated clinic or hospital–the primary purpose of which is to offer and provide immediate, short-term medical care for minor, immediate medical conditions on a regular or routine basis.

Utilization Review
A process of evaluating use and consumption of health care services, along with level and intensity of care, for appropriateness and efficiency.


W

WebMD Office®
An internet site designed specifically for health care providers that offers secure encrypted transactions, including eligibility, provider number search, secure mail, referrals and claim status with adjustments.

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