Guide to Healthcare Terms and Acronyms

Healthcare has a language all its own, full of complex terms and acronyms that can be confusing. NCHA has compiled this guide to healthcare terms and acronyms that provides brief definitions for many of the industry’s medical, financial and government terms, as well as descriptions of government agencies and most of our peer provider organizations in North Carolina. You can use the search function to find a specific definition or terms pertaining to a topic, or use the alphabetical listing with acronyms included as applicable. Web links are provided for many of the agencies and organizations in our glossary.  Terms included in the glossary also are highlighted throughout text on the entire website.

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• a

• Academic medical center (AMC)
  An academic medical center teaching hospital serves as a primary teaching site for a school of medicine and at least one other health professional school, providing undergraduate, graduate and(...)
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• Accountable Care Organization (ACO)
  A group of providers or suppliers or a network of groups, often affiliated with a hospital, that are jointly responsible for the cost and quality of health care provided to Medicare(...)
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• Accounts Payable (A/P)
  The aggregate of money owed by the health care practice or hospital to its suppliers and employees.
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• Accounts Receivable (A/R)
  A term used to denote money owed to your practice for services you have rendered and billed.
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• Accreditation
  Approval by an authorizing agency for institutions and programs that meet or exceed a set of pre-determined standards. Participation is voluntary.
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• Activities of daily living (ADLs)
  Activities performed as part of a person's daily routine of self care such as bathing, dressing, toileting, and eating.
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• Acute care
  Hospital care given to patients who generally require a stay of several days that focuses on a physical or mental condition requiring immediate intervention and constant medical attention,(...)
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• Acute Myocardial Infarction (AMI)
  The medical name for a heart attack. A heart attack is a life-threatening condition that occurs when blood flow to the heart muscle is abruptly cut off, causing tissue damage. This is usually(...)
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• Adjudication
  The process of determining the reimbursement applicable to a particular claim.
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• Adjusted Patient Day (APD)
  A commonly used patient load indicator that measures the number of days of patient care per year in hospitals. It is a number calculated by the American Hospital Association (AHA) based on its(...)
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• Adjusted Payment Rate (APR)
  The Medicare capitated payment to risk-contract HMOs. For a given health plan, the APR is determined by adjusting county-level AAPCCs to reflect the relative risks of the plan’s enrollees.
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• Administrative costs
  Costs related to activities such as utilization review, marketing, medical underwriting, commissions, premium collection, claims processing, insurer profit, quality assurance, and risk(...)
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• Admission/Discharge Transfer System (ADT)
  Holds valuable patient information such as a medical record number, age, name, and contact information. Using the ADT system, patient information can be shared, when appropriate, with other(...)
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• Advance directive
  A document that patients complete to direct their medical care when they are otherwise unable to communicate their own wishes.
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• Advanced Practice Registered Nurse (APRN)
  A registered nurse who is approved by the Board of Nursing to practice nursing in a specified area of advanced nursing practice. APRN is an umbrella term given to a registered nurse who has met(...)
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• Adverse Drug Event (ADE)
  An injury resulting from medical intervention related to a drug.
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• Adverse Drug Reaction (ADR)
  A broad term referring to unwanted, uncomfortable, or dangerous effects that a drug may have.
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• Adverse event
  An injury resulting from a medical intervention that is not due to the underlying condition of the patient.
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• Affiliation
  A form of cooperative agreement in which organizations coordinate and integrate their activities without completely merging or consolidating.
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• Affordable Care Act
  The health reform law enacted in March 2010. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010 and was amended by the Health(...)
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• Agency for Healthcare Research and Quality (AHRQ)
  A federal agency within the Public Health Service responsible for research on quality, appropriateness, and cost of health care. AHRQ also centralizes access to state inpatient data.(...)
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• Allowable charge
  The maximum fee that a health plan will reimburse a provider for a given service.
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• Allied health personnel
  Specially trained and often licensed health workers other than physicians, dentists, optometrists, chiropractors, podiatrists, and nurses. They do not usually engage in independent practice.(...)
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• Allowable costs
  Charges for services rendered or supplies furnished by a health provider that qualify as covered expenses for insurance purposes.
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• Alternative delivery
  An alternative to traditional inpatient care, such as ambulatory care, home health care, and same-day surgery.
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• Alternative medicine
  Treatment procedures that are not a usual component of mainstream medicine, often due to lack of supporting experimental data.
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• Alternative Payment Model/Mechanisms (APM)
  A method of paying for services in which providers can voluntary choose to participate that is different from the standard payment method used to pay those providers.
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• Ambulatory care
  Care given to patients who do not require overnight hospitalization.
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• Ambulatory patient group (APG)
  The Medicare program's prospective payment system for outpatient services and procedures. Each APG is a classified medical service or procedure. Unlike diagnosis related group (DRG)(...)
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• Ambulatory payment classification (APC)
  Groups or groupings of medical procedures and services used as a basis for reimbursement under the Medicare outpatient prospective payment system (OPPS).
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• Ambulatory setting
  An institutional health setting in which organized health services are provided on an outpatient basis, such as a surgery center, clinic, or other outpatient facility. Ambulatory care settings(...)
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• Ambulatory Surgical Center (ASC)
  Modern health care facilities focused on providing same-day surgical care, including diagnostic and preventive procedures.
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• American Academy of Family Physicians (AAFP)
  The mission of the AAFP is to improve the health of patients, families, and communities by serving the needs of members with professionalism and creativity. (also see NCAFP)
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• American Academy of Pediatrics (AAP)
  The mission of the American Academy of Pediatrics is to attain optimal physical, mental, and social health and well-being for all infants, children, adolescents and young adults. (also see NCPeds)
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• American Association of Colleges of Nursing (AACN)
  AACN works to establish quality standards for nursing education; assists schools in implementing those standards; influences the nursing profession to improve health care; and promotes public(...)
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• American Board of Internal Medicine (ABIM)
  A physician-led, non-profit, independent evaluation organization.
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• American College of Healthcare Executives (ACHE)
  An international professional society of nearly 30,000 health care executives based in Chicago. www.ache.org
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• American College of Physicians (ACP)
  The ACP is the largest medical-specialty society in the world. Its mission is to enhance the quality and effectiveness of health care by fostering excellence and professionalism in the practice(...)
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• American College of Surgeons (ACS)
  A scientific and educational association of surgeons that was founded in 1913 to improve the quality of care for the surgical patient by setting high standards for surgical education and practice.
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• American Health Care Association (AHCA)
  A trade association representing nursing homes and long-term care facilities in the United States based in Washington, D.C. www.ahca.org
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• American Health Information Management Association (AHIMA)
  AHIMA ensures that HIM professionals are armed with the skills and tools to act as leaders, using quality information to achieve the Triple Aim of reduced costs, better care, and improved(...)
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• American Hospital Association (AHA)
  A national association that represents allopathic and osteopathic hospitals in the United States based in Washington, D.C., with operational offices in Chicago. www.aha.org
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• American Medical Association (AMA)
  A national association organized into local and regional societies that represent over 700,000 medical doctors in the United States. AMA is based in Chicago. www.ama-assn.org
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• American Nurses Association (ANA)
  The premier organization representing the interests of the nation's 4 million registered nurses. ANA exists to advance the nursing profession by fostering high standards of nursing practice,(...)
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• American Organization of Nurse Executives (AONE)
  The mission of the AONE is to shape health care through innovative and expert nursing leadership. (also see NCONL)
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• American Osteopathic Association (AOA)
  A national association organized into local and regional societies that represent over 43,000 osteopathic physicians in the United States. AOA is based in Chicago and also provides accreditation(...)
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• American Society for Health Care Risk Management (ASHRM)
  A professional membership group of the American Hospital Association (AHA) with nearly 6,000 members representing risk management, patient safety, insurance, law, finance and other related(...)
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• American Society for Healthcare Engineering (ASHE)
  ASHE members include health care facility managers, engineers, architects, designers, constructors, infection control specialists, and others. ASHE is a professional membership group of the(...)
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• American Society of Health Systems Pharmacists (ASHP)
  ASHP helps its members achieve this mission by advocating and supporting the professional practice of pharmacists in hospitals, health systems, ambulatory care clinics, and other settings(...)
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• Americans With Disabilities Act (ADA)
  A federal law that prohibits employers of more than 25 employees from discriminating against any individual with a disability who can perform the essential functions, with or without(...)
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• Ancillary
  A term used to describe additional services performed related to care, such as lab work, X-ray, and anesthesia.
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• Anti-kickback statute
  A federal law that prohibits the paying or receiving of remuneration in exchange for the referral of patients or business paid by a federal health care program.
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• Antitrust
  A situation in which a single entity, such as an integrated delivery system, controls enough of the practices in any one specialty in a relevant market to have monopoly power (e.g., the power to(...)
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• Area Health Education Centers (AHEC)
  The North Carolina Area Health Education Center Program. The mission of the North Carolina AHEC Program is to meet the state’s health and health workforce needs by providing educational programs(...)
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• Assignment of benefits
  The transfer of rights held by one party to another party. In health insurance, the payment for the benefit (health care services) received by the patient is usually assigned to the hospital or(...)
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• Associate Degree in Nursing (ADN)
  A two-year education program in the field of nursing. Nurses usually obtain the associate degree at a junior or community college.
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• Association for Professionals in Infection Control and Epidemiology (APIC)
  The mission of the APIC is to create a safer world through the prevention of infection. This is achieved by the provision of better care to promote better health at a lower cost.
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• Average adjusted per capita cost (AAPCC)
  Payment rates used by the Centers for Medicare and Medicaid Services (CMS) to reimburse managed care organizations for care delivered to Medicare enrollees.
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• Average Daily Census (ADC)
  The average number of patients per day in a hospital over a given period of time.
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• Average length of stay (ALOS)
  A standard hospital statistic used to determine the average amount of time between admission and departure for patients in a diagnosis related group (DRG), an age group, a specific hospital, or(...)
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• b

• Bachelor of Science in Nursing (BSN)
  A four-year college or university program that educates registered nurses, granting a Bachelor of Science degree upon graduation.
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• Bad Debts
  An unpaid obligation by an individual who could pay for the health care service they received. Currently accepted health care accounting practices, and the challenge at the time of a patient’s(...)
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• Balance billing
  A provider's billing of a covered person directly for charges above the amount reimbursed by the health plan. This may or may not be allowed, depending upon the contractual arrangements between(...)
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• Balanced Budget Act of 1997 (BBA)
  A federal law enacted by U.S. Congress that made numerous changes to various titles of the Social Security Act, contained significant changes to the Medicare and Medicaid programs, and created a(...)
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• Balanced Budget Refinement Act of 1999 (BBRA)
  A federal law enacted by U.S. Congress that restored an estimated $17 billion to the Medicare program.
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• Basic Life Support (BLS)
  A level of medical care which is used for victims of life-threatening illnesses or injuries until they can be given full medical care at a hospital. It can be provided by trained medical(...)
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• Bed size
  The number of beds a hospital has been designed and constructed to contain. It may also refer to the number of beds set up and staffed for use.
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• Behavioral health care
  Mental health services, including services for alcohol and substance abuse.
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• Behavioral Health Urgent Care
  Similar to a medical urgent care, behavioral health urgent cares have non-traditional hours and can quickly provide medication adjustments, referrals to ongoing care in the community, or assess(...)
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• Benchmarking
  A method of comparing the procedures and results of a process, system or, operation under study with a similar process, system, or operation under study that is generally recognized as outstanding.
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• Beneficiary
  A person designated by an insuring organization as eligible to receive insurance benefits.
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• Benefits Improvement and Protection Act of 2000 (BIPA)
  A federal law enacted by U.S. Congress that, among other provisions, restored an estimated $11.5 billion over five years to hospitals under Medicare, Medicaid, and other federal and state health(...)
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• Best Practices
  The most up-to-date patient care interventions, scientifically proven to result in the best patient outcomes and minimize patients' risk of death or complications. A superior method or(...)
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• Blue Cross Blue Shield of North Carolina (BCBSNC)
  North Carolina’s Blue Cross Blue Shield insurance plan. www.bcbsnc.com
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• Board-certified
  A clinician who has passed the national examination in a particular field. Board certification is available for most physician specialties, as well as for many allied medical professions.
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• Bundled payments
  A comprehensive payment covering the costs of all applicable services and other appropriate services furnished to an individual during an episode of care.
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• c

• Capitation (CAP)
  A stipulated dollar amount established to cover the cost of health care delivered for a person or group of persons. The term usually refers to a negotiated per capita rate to be paid(...)
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• Cardiac Intensive Care Unit (CICU)
  A hospital ward specialized in the care of patients with heart attacks, unstable angina, cardiac dysrhythmia and (in practice) various other cardiac conditions that require continuous monitoring(...)
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• Cardiopulmonary Resuscitation (CPR)
  A medical procedure involving repeated compression of a patient's chest, performed in an attempt to restore the blood circulation and breathing of a person who has suffered cardiac arrest.
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• Care Share Health Alliance
  Care Share is a private/public partnership that helps develop community-based, integrated networks of healthcare for low-income and uninsured North Carolinians. www.caresharehealth.org
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• CareLearning
  An online education service of more than 40 state hospital associations (including NCHA) along with the American Hospital Association (AHA) for the purpose of delivering more cost-effective(...)
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• Case management
  A program that is designed to assess the continuing needs of members with chronic health problems.
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• Case manager
  Assists physicians in meeting an individual’s health care needs through coordination of services and utilization of resources in order to promote high quality, cost effective outcomes.
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• Case mix index
  A measure of relative severity of medical conditions of a hospital's patients.
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• Case Mix Index (CMI)
  A relative value assigned to a diagnosis-related group (DRG/MSDRG) of patients in a medical care environment. The CMI value is used in determining the allocation of resources to care for and/or(...)
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• Catchment area
  The specific geographic area for which a particular institution is responsible.
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• Catheter Associated Urinary Tract Infection (CAUTI)
  An infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney. UTIs are the most common type of healthcare-associated infection reported to the National(...)
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• Center for Medicare & Medicaid Innovation (CMMI)
  The Center for Medicare & Medicaid Innovation (the CMS Innovation Center) fosters health care transformation by finding new ways to pay for and deliver care that improve care and health while(...)
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• Centers for Disease Control and Prevention (CDC)
  An agency within the U.S. Department of Health and Human Services (HHS) that serves as the central point for consolidation of disease control data, health promotion, and public health programs.(...)
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• Centers for Medicare and Medicaid Services (CMS)
  An agency within the U.S. Department of Health and Human Services (HHS) that is responsible for the administration of the Medicare and Medicaid programs. Formerly called the Health Care(...)
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• Central Line-Associated Bloodstream Infection (CLABSI)
  A serious infection that occurs when germs (usually bacteria or viruses) enter the bloodstream through the central line.
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• Certificate of need (CON)
  North Carolina hospitals and physicians have to obtain approval from the NC Division of Health Service Regulation for activity such as constructing or modifying hospitals, purchasing certain(...)
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• Certificate of Coverage (COC)
  When you enroll in a health insurance plan, you are given a certificate of coverage. This document explains the health benefits you and your dependents have under the plan.
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• Charge
  The amount a doctor or other healthcare provider bills a patient. Direct and indirect expenses incurred by the hospital in providing the services, or hospital costs, are one factor in the(...)
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• Charity care
  Health care services provided free of charge or at a substantial discount. North Carolina hospitals want their communities to know their financial assistance policies and what benefits they are(...)
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• Cherry-picking
  A colloquial term for selecting only the patients least likely to require costly medical services or only those patients with sufficient insurance coverage to pay for required services.
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• Chief Executive Officer (CEO)
  Principal executive leader of an organization.
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• Chief Financial Officer (CFO)
  An executive leader who oversees financial operations.
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• Chief Medical Officer (CMO)
  The title refers to a key member of a Senior Executive team, engaged in defining the overall business strategy and direction of an organization. CMO is used in many countries for the senior(...)
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• Chief Nursing Officer (CNO)
  A CNO is responsible for overseeing and coordinating an organization's nursing department and its daily operations.
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• Chief Operating Officer (COO)
  An executive leader who oversees day-to-day management and internal operations.
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• Children’s Health Insurance Program (CHIP)
  A state-administered program funded partly by the federal government that allows states to expand health coverage to uninsured, low-income children not eligible for Medicaid. North Carolina’s(...)
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• Chronic Obstructive Pulmonary Disease (COPD)
  A chronic inflammatory lung disease that causes obstructed airflow from the lungs.
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• Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)
  A US federally funded health program that provides beneficiaries with medical care, supplemental to that available in US military and Public Health Service facilities. (also see TRICARE)
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• Civilian Health and Medical Program of the Veterans Administration (CHAMPVA)
  A comprehensive health care program in which the VA shares the cost of covered health care services and supplies with eligible beneficiaries.
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• Claim
  A request for payment for benefits received or services rendered.
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• Clinical Guideline
  A treatment regime, agreed upon by consensus, which includes all the elements of care regardless of the effect on patient outcomes. Also called a clinical pathway.
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• Clinical Laboratory Improvement Amendments of 1988 (CLIA)
  Regulations that include federal standards applicable to all U.S. facilities or sites that test human specimens for health assessment or to diagnose, prevent, or treat disease.
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• Clinical Measures
  Measures representing processes of care and patient outcomes widely accepted as important to quality care, consistently and accurately tracked in order to determine quality performance in a(...)
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• Clostridium difficile (C. diff)
  A bacterium transferred to patients mainly through the hands of health care personnel who have touched a contaminated surface or item and which causes diarrhea and more serious intestinal(...)
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• Co-insurance
  The percentage of the allowed amounts for covered services that the insurer will pay after a covered person’s deductible is met.
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• Co-payment
  The fixed-dollar amount paid for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service. Also referred to as ‘copay.’
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• Code of Federal Regulations (CFR)
  A publication of the federal government that consists of all regulations of federal departments and agencies. www.gpoaccess.gov/cfr/index.html
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• Commitment examiner
  A professional whose scope of practice includes diagnosing psychiatric or substance use disorders and conducting mental status examinations. These professionals include the following:(...)
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• Community-based Care Transitions Program (CCTP)
  Created by Section 3026 of the Affordable Care Act, the CCTP tested models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare(...)
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• Community-Based Organization (CBO)
  A public or private nonprofit organization of demonstrated effectiveness that is representative of a community or significant segments of a community; and provides educational or related(...)
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• Community Benefit
  Programs or services that address community health needs — particularly those of the poor, minorities, and other underserved groups — and provide measurable improvement in health access, health(...)
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• Community Care of NC (CCNC)
  The Community Care of North Carolina program is building community health networks organized and operated by community physicians, hospitals, health departments, and departments of social(...)
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• Community crisis plans
  Each LME/MCO will create a community crisis services plan, which will identify the following: 1) site(s) for the first examination and health screening; 2) trainings available, such as(...)
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• Community Health Center (CHC)
  An ambulatory health care program (defined under section 330 of the Public Health Service Act) usually serving a catchment area which has scarce or nonexistent health services or a population(...)
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• Community health needs assessments (CHNA)
  A systematic examination of the health status indicators for a given population that is used to identify key problems and assets in a community. CHNA and implementation strategies are required(...)
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• Computed Tomography Scan (CT or CAT Scan)
  A powerful x-ray that takes 360-degree pictures of internal organs, the spine, and vertebrae.
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• Computerized physician order entry (CPOE)
  A system that allows physicians to write medical orders for their hospitalized patients using a clinical software application.
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• Conditions of Participation (CoP)
  The federal regulations hospitals must comply with in order to qualify for Medicare reimbursement.
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• Conference committee
  A bi-partisan committee made up of equal members from each chamber of the North Carolina General Assembly or U.S. Congress that is responsible for working out differences between House- and(...)
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• Congressional Budget Office (CBO)
  A non-partisan office that provides U.S. Congress with cost estimates of legislative proposals and calculates estimates related to the federal budget. www.cbo.gov/
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• Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)
  The 1985 federal spending plan which included several health provisions and protections, including protection against denial of emergency medical care to patients who are unable to pay and the(...)
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• Consumer Price Index (CPI)
  Widely used as an indicator of changes in the cost of living, as a measure of inflation, and as a means of studying price trends. Measures the change in cost of a constant bundle of goods and(...)
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• Continuing Medical Education (CME)
  Provisions and procedures used by third-party payers to determine the amount payable when a claimant is covered under two or more health plans.
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• Continuum of Care
  The full array of services, from prevention to treatment to rehabilitation and maintenance, required to support optimum health of a population.
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• Coordination of Benefits (COB)
  Provisions and procedures of insurers used to avoid duplicate payments when claims are covered by more than one insurance company.
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• Core Measures
  Specific clinical measures that, when viewed together, permit a robust assessment of the quality of care provided in a given focus area, such as acute myocardial infarction (AMI).
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• Cost
  The expenses incurred by a hospital in providing care. The hospital costs attributed to a particular episode of care include the direct costs plus an appropriate proportion of the overhead(...)
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• Cost shifting
  A situation in which a health care provider compensates for the effect of decreased revenue from one payer by increasing charges to another payer.
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• Cost-to-charge ratio (CCR)
  The total amount of money required to operate a hospital, divided by the sum of the revenues received from patient care and all other operating revenues.
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• Coverage
  A person has coverage if all or part of his or her health care costs are paid either by insurance or by the government.
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• Covered Lives
  A person has coverage if all or part of his or her health care costs are paid either by insurance or by the government.
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• Covered Services
  Specific health care benefits, services and products a health plan or insurer will provide reimbursement for.
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• Credentialing
  The process of reviewing a practitioner’s academic, clinical, and professional ability as demonstrated in the past to determine if criteria for clinical privileges are met.
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• Critical Access Hospital (CAH)
  A designation given to eligible rural hospitals, or those grandfathered as rural, by the Centers for Medicare and Medicaid Services (CMS).
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• Critical Care Unit (CCU)
  Synonymous with intensive or special care unit. Service area of a hospital established to provide continuous intensive care to critically ill patients.
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• Critical Pathway
  A treatment protocol including only the vital components or items proved to affect patient outcomes.
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• Current Procedural Terminology (CPT)
  A medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations.
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• d

• Department of Health and Human Services (DHHS)
  The North Carolina Department of Health and Human Services is the largest agency in state government, responsible for ensuring the health, safety and well being of all North Carolinians,(...)
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• Department of Corrections (DOC)
  A governmental agency tasked with the responsibility of overseeing the incarceration of persons convicted of crimes within a particular jurisdiction. In the U.S., all 50 states have State(...)
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• Department of Homeland Security (DHS)
  A cabinet department of the United States federal government with responsibilities in public security, roughly comparable to the interior or home ministries of other countries.
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• Department of Justice (DOJ)
  A federal executive department of the U.S. government, responsible for the enforcement of the law and administration of justice in the United States, equivalent to the justice or interior(...)
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• Department of Labor (DOL)
  A cabinet-level department of the U.S. federal government responsible for occupational safety, wage and hour standards, unemployment insurance benefits, reemployment services, and some economic(...)
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• Diagnostic related group (DRG)
  A classification system that groups patients by common characteristics requiring treatment.
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• Discharge planning
  The evaluation of patients' health needs for appropriate care after discharge from an inpatient setting.
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• Dispense as Written (DAW)
  Instruction by a physician to a pharmacist to provide the recipient with the prescription exactly as it was written, or not to substitute a generic form of the drug.
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• Disproportionate share hospital (DSH)
  A hospital that provides care to a very high number of uninsured or underinsured patients.
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• ED Diversion
  The routing of patients to other hospitals because an emergency room is temporarily at maximum capacity.
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• Division of Health Service Regulation (DHSR)
  NC Division of Health Service Regulation, part of the NC Department of Health and Human Services. The mission of the Division of Health Service Regulation is to provide for the health, safety(...)
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• Division of Medical Assistance (DMA)
  DMA manages the Medicaid and Health Choice programs. The mission of DMA is to provide access to high quality, medically necessary health care for eligible North Carolina residents through(...)
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• Division of Mental Health/Developmental Disabilities/ Substance Abuse Services (DMH/DD/SAS)
  DMH/DD/SAS provides people with, or at risk of, mental illness, developmental disabilities and substance abuse problems and their families the necessary, prevention, intervention, treatment,(...)
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• Division of Public Health (DPH)
  North Carolina Public Health works to promote and contribute to the highest possible level of health for the people of North Carolina. publichealth.nc.gov/
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• Doctor of osteopathy (DO)
  A licensed physician who is a graduate from an accredited school of osteopathic medicine.
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• Doughnut hole
  A gap in prescription-drug coverage for some Medicare recipients. In 2012 these Medicare beneficiaries have no drug coverage once their medication costs exceed $2,930 until they have spent(...)
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• Drug Enforcement Administration (DEA)
  A United States federal law enforcement agency under the United States Department of Justice, tasked with combating drug smuggling and use within the United States.
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• Drug formulary
  A listing of prescription medications and appropriate dosages felt to be the most useful and cost effective for patient care. Health plans that have adopted a “closed, select or mandatory”(...)
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• Durable medical equipment (DME)
  Equipment that can stand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of illness or injury, and is appropriate(...)
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• Durable power of attorney
  A document in which individuals select another person to act on their behalf in the event they become incapacitated. The document may identify specific activities, such as managing the(...)
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• e

• Early Periodic Screening, Diagnosis and Treatment (EPSDT)
  All children under age 21 enrolled in Medicaid through the categorically needy pathway are entitled to the Early and Periodic Screening, Diagnostic, and Treatment benefit, which requires states(...)
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• Electrocardiogram (ECG/EKG)
  A test that records the electrical activity of your ticker through small electrode patches that a technician attaches to the skin of your chest, arms, and legs.
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• Electroencephalogram (EEG)
  A test or record of brain activity produced by electroencephalography.
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• Electromyogram (EMG)
  An electrodiagnostic medicine technique for evaluating and recording the electrical activity produced by skeletal muscles.
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• Electronic Claims Submission (ECS)
  A digital representation of a medical bill generated by a provider or by the provider’s billing agent for submission using telecommunications to a health insurance payer.
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• Electronic Data Interchange (EDI)
  The automated exchange of data and documents in a standardized format. In health care, some common uses of this technology include claims submission and payment, eligibility, and referral(...)
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• Electronic Health Records (EHR)
  An EHR is generated and maintained within an institution, such as a hospital, integrated delivery network, clinic, or physician office, to give patients, physicians and other health care(...)
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• Electronic Medical Records (EMR)
  The EMR can be defined as the legal patient record created in hospitals and ambulatory environments that is the data source for the EHR.
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• Emergency Department (ED)
  A medical treatment facility specializing in emergency medicine, the acute care of patients who present without prior appointment; either by their own means or by that of an ambulance.
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• Emergency Medical Services (EMS)
  A system of health care professionals, facilities, and equipment providing emergency care.
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• Emergency Medical Technician (EMT)
  A person certified to provide pre-hospital emergency medical treatment.
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• Emergency Medical Treatment and Labor Act (EMTALA)
  An act created by Congress as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985. It is designed to prevent hospitals from refusing to treat patients or transferring them(...)
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• Emergency Operations Plan (EOP)
  Hospitals are required to have an Emergency Operations Plan which describes how a facility will respond to and recover from all hazards. It is inclusive of the six critical elements within the(...)
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• Employee Assistance Program (EAP)
  A voluntary, work-based program that offers free and confidential assessments, short-term counseling, referrals, and follow-up services to employees who have personal and/or work-related problems.
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• Employee Retirement Income Security Act (ERISA)
  A federal law that exempts self-insured health plans from state laws governing health insurance, including contribution to risk pools, prohibitions against disease discrimination, and other(...)
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• Employer mandate
  A requirement that employers provide health insurance for employees, or pay a financial penalty.
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• Employer-sponsored health insurance
  Health insurance paid for, in whole or in part, by businesses on behalf of their employees as part of an employee benefit package. Most large employers in America offer group health insurance(...)
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• End-Stage Renal Disease (ESRD)
  Occurs when chronic kidney disease — the gradual loss of kidney function — reaches an advanced state. In end-stage renal disease, your kidneys are no longer able to work as they should to meet(...)
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• Environmental Control Unit (ECU)
  Devices that allow people with mobility impairments to operate electronic devices, including televisions, computers, lights, appliances, and more.
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• Environmental Protection Agency (EPA)
  A federal and state agency responsible for programs to control air, water and noise pollution, solid waste disposal and other environmental concerns. www.epa.gov
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• Episode of care
  An interval of care by a health care facility or provider for a specific medical problem or condition. It may be continuous or it may consist of a series of intervals marked by one or more brief(...)
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• Essential Health Benefits
  A comprehensive package of benefits that insurance policies must cover in order to be certified and offered in Exchanges. All Medicaid state plans must cover these services by 2014. Essential(...)
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• Evidence-based medicine
  The wise and careful use of the best available scientific research and practices with proven effectiveness in daily medical decision-making, including individual clinical practice decisions, by(...)
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• Exclusions
  Clauses in an insurance contract that deny coverage for select individuals, groups, locations, properties or risks.
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• Explanation of Benefits (EOB)
  A statement sent by a health insurance company to covered individuals explaining what medical treatment/services were paid for on their behalf.
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• Extended Care Facility
  An institution devoted to providing medical, nursing, or custodial care for an individual over a prolonged period, such as during the course of a chronic disease or the rehabilitation phase(...)
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• f

• Facility based crisis center
  A specialized non-hospital facility for individuals experiencing a behavioral health crisis. The facility offers 24-hour short-term treatment.
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• Failure mode effect analysis (FMEA)
  A systematic method of identifying and preventing problems (errors) before they occur.
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• False Claims Act
  A federal law that imposes liability for treble damages and fines of $5,000 to $10,000 for knowingly submitting to the federal government a false or fraudulent claim for payment.
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• Family Medical Leave Act (FMLA)
  Is a United States labor law requiring covered employers to provide employees with job-protected and unpaid leave for qualified medical and family reasons.
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• Family Practitioner
  A physician who specializes in caring for the entire family.
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• Most-favored-nation clause (MFN)
  A provision requiring the contracting physician, hospital, or group to provide an insurer with the lowest price it charges any other insurer.
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• Federal Communications Commission (FCC)
  An independent agency of the United States government created by statute to regulate interstate communications by radio, television, wire, satellite, and cable.
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• Federal Emergency Management Agency (FEMA)
  An agency of the United States Department of Homeland Security. The agency's primary purpose is to coordinate the response to a disaster that has occurred in the United States and that(...)
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• Federal Employee Health Benefits Program (FEHBP)
  A government program that allows some 8 million federal employees, including members of Congress, to purchase private health insurance. The government provides a set amount of money to(...)
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• Federal Financial Participation (FFP)
  The portion paid by the federal government to states for their share of expenditures for providing Medicaid services and for administering the Medicaid program and certain other human service(...)
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• Federal Fiscal Year (FFY)
  The federal fiscal year is the accounting period for the federal government which begins on October 1 and ends on September 30.
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• Federal Medical Assistance Percentage (FMAP)
  The share of each state's Medicaid program paid by the federal government, based on the state's per capita income.
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• Federal poverty guidelines
  The official annual income level for poverty as defined by the federal government. Under the 2011 guidelines, the federal poverty level for a family of four is $22,350.
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• Federal Poverty Level (FPL)
  A measure of income level issued annually by the Federal Department of Health and Human Services and used to determine eligibility for certain programs and benefits. For 2012, the FPL was an(...)
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• Federal Register
  An official publication of the federal government that provides final and proposed regulations of federal legislation. www.gpoaccess.gov/fr/index.html
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• Federal Trade Commission (FTC)
  A federal agency created to protect consumers against unfair methods of competition and deceptive business practices, such as sales fraud and price fixing. Investigates and applies antitrust(...)
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• Federally Qualified Health Center (FQHC)
  A primary care clinic located in an underserved area that meets the health care needs of special populations and receives special reimbursement for doing so.
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• Federation of American Hospitals (FAH)
  A trade association for investor-owned hospitals in the United States.
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• Fee for Service (FFS)
  A payment model where services are unbundled and paid for separately. In health care, it gives an incentive for physicians to provide more treatments because payment is dependent on the quantity(...)
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• Fee schedule
  A comprehensive listing of fees used by either a health care plan or the government to reimburse providers on a fee-for-service basis.
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• Fellow of American College of Healthcare Executives (FACHE)
  The highest credential awarded by the American College of Healthcare Executives (ACHE).
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• Financial Accounting Standards Board (FASB)
  A private, non-profit organization standard setting body whose primary purpose is to establish and improve generally accepted accounting principles (GAAP) within the United States in the(...)
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• Financial Assistance Policy
  The standard course of action a hospital requires for patients to receive free or reduced-cost care. The Federal government requires hospitals to ‘charge’ all patients, including the uninsured,(...)
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• Fiscal intermediary
  The Medicare Part A claims processing contractor. North Carolina’s is Palmetto GBA.
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• Fiscal Year (FY)
  The completion of a one-year, or 12-month, accounting period. Also referenced as Fiscal Year End (FYE)
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• Flexible Spending Account (FSA)
  A special account you put money into that you use to pay for certain out-of-pocket health care costs.
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• Food and Drug Administration (FDA)
  An agency within the federal government that is responsible for regulations pertaining to food and drugs sold in the United States. www.fda.gov
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• Freedom of Information Act (FOIA)
  A federal freedom of information law that allows for the full or partial disclosure of previously unreleased information and documents controlled by the United States government.
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• Freestanding Emergency Department (FSED)
  A facility that is structurally separate and distinct from a hospital and provides emergency care.
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• Freestanding outpatient surgical center
  A health care facility, physically separate from a hospital, that provides pre-scheduled, outpatient surgical services.
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• Full-Time Equivalent (FTE)
  The ratio of the total number of paid hours during a period (part time, full time, contracted) by the number of working hours in that period Mondays through Fridays.
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• g

• GAP Insurance
  An individual insurance policy which can be purchased to cover certain health care services and costs that are not provided by insurance.
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• General Accepted Accounting Principles (GAAP)
  A collection of commonly-followed accounting rules and standards for financial reporting.
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• General practitioner (GP)
  A physician whose practice is based on a broad understanding of all illnesses and who does not restrict his/her practice to any particular field of medicine.
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• Generic Drug
  Pertaining to the descriptive or nontrade name of a drug or other product; for example, diazepam is the generic name for Valium.
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• Geographic Adjustment Factor (GAF)
  Changes in reimbursement based on estimated operating expenses in different regions across the country.
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• Government Accountability Office (GAO)
  A non-partisan investigative arm of U.S. Congress that evaluates federal programs as an oversight of federal spending, efficiency, and performance. www.gao.gov
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• Governmental Accounting Standards Board Financial Accounting (GASB)
  The source of generally accepted accounting principles (GAAP) used by state and local governments in the United States.
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• Graduate medical education (GME)
  Medical education as an intern, resident, or fellow after graduating from a medical school.
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• Gross Domestic Product (GDP)
  The total value of goods produced and services provided in a country during one year.
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• Gross National Product (GNP)
  The total value of goods produced and services provided by a country during one year, equal to the gross domestic product plus the net income from foreign investments.
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• Group insurance
  Any insurance policy or health services contract by which groups of employees (and often their dependents) are covered under a single policy or contract, issued by their employer or other group(...)
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• Group Practice
  A formal association of three or more physicians, dentists, or other health professionals providing services, with income from the medical practice distributed to the group members according to(...)
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• Group Purchasing Organization (GPO)
  An entity that is created to leverage the purchasing power of a group of businesses to obtain discounts from vendors based on the collective buying power of the GPO members.
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• h

• Health Benefits Exchanges
  An insurance marketplace where individuals and small business can purchase qualified health benefit plans starting in 2014. Individuals making between 100% and 400% of the Federal Poverty Level(...)
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• Healthcare-acquired infection (HAI)
  An infection acquired by an individual while receiving care or services in a hospital or other health care facility.
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• Health care durable power of attorney
  A document in which individuals select another individual to make health care decisions for them in the event they become incapacitated. A health care durable power of attorney should be(...)
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• Health Care Financing Administration (HCFA) (CMS)
  Federal agency that administers Medicare and oversees state administration of Medicaid. HCFA resides within the Department of Health and Human Services. Renamed as CMS (Centers for Medicare and(...)
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• Healthcare system
  A corporate body that owns and/or manages multiple entities including hospitals, long-term care facilities, other institutional providers and programs, physician practices, and/or insurance(...)
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• Health and Human Services (HHS)
  The U.S. Department of Health and Human Services (HHS) is a department within the executive branch of the federal government responsible for Social Security and federal health programs in the(...)
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• Health Information Technology for Economic and Clinical Health Act (HITECH)
  The Health Information Technology for Economic and Clinical Health Act (HITECH) portion of the ARRA provides $17.2B in reimbursement payment incentives and $2B in competitive planning and(...)
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• Health insurance
  A contract that requires a health insurer to pay some or all of a patient’s health care costs in exchange for a premium.
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• Health insurance exchange
  A government-administered marketplace or portal (website) where private or public insurance policies are sold.
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• Health Insurance Portability and Accountability Act (HIPAA)
  The Health Insurance Portability and Accountability Act (HIPAA) of 1996 included a series of "administrative simplification" provisions that required the Department of Health and Human Services(...)
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• Health maintenance organization (HMO)
  An entity that offers prepaid, comprehensive health coverage for both hospital and physician services with specific health care providers using a fixed fee structure or capitated rates.
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• Health Plan Employer Data and Information Set (HEDIS)
  A set of performance measures designed to standardize the way health plans report data to employers. HEDIS measures five major areas of health plan performance: quality, access and patient(...)
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• Health Professional Shortage Area (HPSA)
  Areas designated by the federal Health Resources and Services Administration (HRSA) as having shortages of primary care, dental care, or mental health providers and may be geographic (a county(...)
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• Health Resource Service Administration (HRSA)
  A federal agency within the U.S. Department of Health and Human Services that provides health care grant programs. www.hrsa.gov
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• Health Resources and Services Administration (HRSA)
  HRSA is a component of the U.S. Department of Health and Human Services.
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• Health savings account (HSA)
  A tax-deductible personal savings account, usually offered by employers along with high-deductible health-insurance plans, used to pay for medical expenses.
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• Health screening
  An appropriate screening suitable for the symptoms presented and to determine if an emergency medical condition exists. The health screen will be performed by the commitment examiner or other(...)
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• Healthcare access
  A patient's ability to obtain medical care. The ease of access is determined by components such as the availability of medical services and their acceptability to the patient, availability of(...)
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• Healthcare Failure Mode and Effect Analysis (HFMEA)
  A prospective assessment that identifies and improves steps in a process, thereby reasonably ensuring a safe and clinically desirable outcome. A systematic approach to identify and prevent(...)
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• Healthcare Financial Management Association (HFMA)
  A professional association of health care finance managers. www.hfma.org
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• High deductible health plan (HDHP)
  A health insurance plan with lower premiums and higher deductibles than a traditional health plan. Being covered by an HDHP is also a requirement for having a health savings account.
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• Hill-Burton Act
  Following World War II, the federal government encouraged the building of hospitals and other health care facilities by providing funds for expansion and development. These funds, made available(...)
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• Home and Community-Based Services (HCBS)
  Program that allows Medicaid beneficiaries to receive services in their own home or community rather than institutions or other isolated settings. These programs serve a variety of targeted(...)
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• Home health agency (HHA)
  An organization that provides medical, therapeutic, or other health services in patients' homes.
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• HOSPAC
  NCHA’s Political Action Committee. www.ncha.org/hospac
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• Hospice
  A facility or program that is licensed, certified, or otherwise authorized by law, that provides supportive care of the terminally ill.
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• Hospital-acquired condition (HAC)
  Conditions that could reasonably have been prevented through the application of evidence-based guidelines.
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• Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
  A patient satisfaction survey required by CMS (the Centers for Medicare and Medicaid Services) for all hospitals in the United States. The Survey is for adult inpatients, excluding psychiatric(...)
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• Hospital Improvement Innovation Networks (HIINs)
  Work at the regional, State, national or hospital system level to sustain and accelerate national progress and momentum towards continued harm reduction in the Medicare program, help identify(...)
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• Hospital Incident Command System (HICS)
  An incident management system based on the Incident Command System that helps hospitals improve emergency management response and recovery capabilities for planned and unplanned events.
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• Hospital market basket
  Components of the overall cost of health care used in determining the consumer price index.
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• Hospital Market Basket Index
  An inflationary measure of the cost of goods and services purchased by health care facilities, often used to determine growth in reimbursement rates.
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• Hospital Quality Alliance
  A public-private collaboration to improve the quality of care provided by U.S. hospitals by measuring and publicly reporting a set of measures. An element of the program is the Hospital Compare(...)
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• Hospitalist
  Physician specialists in inpatient medicine who spend at least 25 percent of their professional time serving as the physicians-of- record for inpatients, returning the patients back to the care(...)
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• Human Immunodeficiency Virus (HIV)
  A virus spread through certain body fluids that attacks the body’s immune system, specifically the CD4 cells, often called T cells.
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• i

• Immediate Jeopardy (IJ)
  A crisis situation in which the health and safety of individual(s) are at risk.
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• Incapable
  As determined by a physician or psychologist, a person who lacks capacity to make or communicate mental health treatment decisions. Incapable is a different standard from incompetent.
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• Incurred but Not Reported (IBNR)
  IBNR claims are the amount owed by an insurer to all valid claimants who have had a covered loss but have not yet reported it.
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• Independent Practice Association (IPA)
  A US term for an association of independent physicians, or other organization that contracts with independent physicians, and provides services to managed care organizations on a negotiated per(...)
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• Indicator
  1. A measure used to determine, over time, performance of functions, processes and outcomes. 2. A statistical value that provides an indication of the condition or direction over time of(...)
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• Indigent medical care
  Care given by health care providers to patients who are unable to pay for it.
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• Individual mandate
  A requirement that every American have health insurance, which would be enforced through financial penalties.
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• Inpatient
  An individual who has been admitted to a hospital for at least 24 hours.
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• Inpatient Admission
  The formal acceptance of a patient who is provided with room, board, and continuous nursing service in an area of the hospital where patients generally reside at least overnight.
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• Inpatient Care
  Care given a registered bed patient in a hospital, nursing home or other medical or post acute institution.
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• Inspector General (IG)
  An official in charge of inspecting a particular institution or activity.
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• Institute for Healthcare Improvement (IHI)
  An independent not-for-profit organization helping to lead the improvement of health care throughout the world.
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• Institute for Safe Medication Practices (ISMP)
  A non-profit organization that educates the healthcare community and consumers about safe medication practices.
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• Institutional Review Board (IRB)
  A type of committee that applies research ethics by reviewing the methods proposed for research to ensure that they are ethical.
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• Insurance deductible
  Out-of-pocket expenses that must be paid by the health insurance subscriber before the insurer will begin reimbursing the subscriber for additional medical expenses.
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• Integrated delivery system
  Collaboration between physicians and hospitals for a variety of purposes. Some models of integration include physician-hospital organization, management-service organization, group practice(...)
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• Integrated Care Delivery System (ICDS)
  Is a system of managed care plans selected to coordinate the physical, behavioral, and long-term care services for individuals over the age of 18 who are eligible for both Medicaid and Medicare.
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• Integrated Payment and Reporting System (IPRS)
  Tracks, pays, and reports on all claims submitted by providers for services rendered. The IPRS system processes and pays claims for the Division of MH/DD/SA Services and Medicaid system. Often,(...)
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• Intensive Care Unit (ICU)
  The area of a hospital where patients with life-threatening illnesses are closely monitored. Also called Critical Care Unit.
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• Intergovernmental Transfers (IGT)
  Transfers of public funds between governmental entities. The transfer may take place from one level of government to another (i.e. counties to states) or within the same level of government.
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• Intermediate care facility
  A facility providing a level of medical care that is less than the degree of care and treatment that a hospital or skilled nursing facility is designed to provide but greater than the level of(...)
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• International Classification of Diseases (ICD)
  The classification of morbidity and mortality information for statistical purposes and for the indexing of hospital records by disease and operations for data storage and retrieval. Provides(...)
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• Intravenous (IV)
  Existing or taking place within, or administered into, a vein or veins.
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• Involuntary Commitment (IVC)
  A legal process through which an individual who is deemed by a qualified agent to have symptoms of severe mental disorder is court-ordered into treatment in a psychiatric hospital (inpatient) or(...)
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• IRS Form 990
  The tax-exempt return most charitable organizations, including hospitals, file with the IRS each year. It includes income, expenditures and activities, as well as compensation of high-level(...)
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• j

• Joint Commission Resources (JCR)
  A subsidiary of the Joint Commission designed to distribute consulting and publication services. www.jcrinc.com
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• k

• Kate B. Reynolds Charitable Trust
  Before her death in 1946, Mrs. Reynolds established the Trust to continue much of the work she had supported during her lifetime. The Trust’s mission is to improve the quality of life and the(...)
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• l

• Lean manufacturing
  An Initiative focused on eliminating all waste in manufacturing processes. Principles of lean include zero waiting time, zero inventory, scheduling (internal customer pull instead of push(...)
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• Leapfrog Group
  A group of Fortune 500 employers and other purchasers of health care, sponsored by the Business Roundtable, focused on patient safety issues. www.leapfroggroup.org
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• Length of stay (LOS)
  The number of days a patient stays in a hospital or other health care facility.
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• Licensed Practical Nurse (LPN)
  A nursing school graduate who has been licensed by a state.
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• Licensed Practical Nurse (LPN)
  A nurse who cares for people who are sick, injured, convalescent, or disabled. LPNs work under the direction of physicians.
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• Life Safety Code
  Standards of construction, protection and occupancy necessary to minimize danger to life from fire, smoke, fumes and panic. The Joint Commission and the Centers form Medicare and Medicaid(...)
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• Living will
  A legal document generated by an individual to guide providers on the desired medical care in cases when the individual is unable to articulate his or her own wishes. (See "advance directive")
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• LME/MCO
  Local Management Entities/ Managed Care Organizations were created by legislation in 2011 to serve Medicaid, uninsured, and underinsured patients with mental illness, intellectual and(...)
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• Local Management Entities (LMEs)
  Formerly known as Area Mental Health Programs, LMEs are regional authorities responsible for managing, coordinating, facilitating, and monitoring the provision of mental health, developmental(...)
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• Long-Term Acute Care Hospital
  Provide care for patients with multiple serious medical conditions requiring a longer stay than encouraged in traditional hospitals.
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• Long-Term Care Facility (LTCF)
  Any residential health care facility that administers health, rehabilitative or personal services for a prolonged period of time.
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• Long-term care hospital (LTCH or LTACH)
  A hospital that specializes in treating patients with serious and often complex medical conditions requiring a longer length of stay than customarily provided by a traditional acute care(...)
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• Long-term care (LTC)
  Care given to patients with chronic illnesses who usually require a length of stay longer than 30 days.
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• m

• MACRA
  see Medicare Access and CHIP Reauthorization Act of 2015
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• Magnet Hospital Recognition Program
  A designation through the American Nurses Credentialing Center that recognizes those institutions that act as a “magnet” by creating a work environment that recognizes and rewards professional(...)
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• Magnetic resonance imaging (MRI)
  A diagnostic technique that uses radio and magnetic waves, rather than radiation, to create images of body tissue and to monitor body chemistry.
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• Malpractice
  The improper treatment of a patient, as by a physician or nurse, resulting in injury.
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• Managed care
  A health care delivery system, comprising a spectrum of financial and structural relationships among purchasers, insurers, providers and consumers designed to favorably affect the balance of(...)
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• Managed Care Organization (MCO)
  A health plan that seeks to manage care. Generally, this involves contracting with health care providers to deliver health care services on a capitated (per-member per-month) basis. (For(...)
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• Management Service Organization (MSO)
  A legal entity that provides practice management, administrative and support services to individual physicians or group practices. An MSO may be a direct subsidiary of a hospital, a joint(...)
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• Master of Science in Nursing (MSN)
  A person holding a master’s degree in nursing.
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• Measles, Mumps, and Rubella (MMR)
  Measles is a very contagious disease caused by a virus. It spreads through the air when an infected person coughs or sneezes. Mumps is a contagious disease that is caused by a virus. Mumps(...)
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• Medicaid
  A state-administered health insurance program funded partly by the federal government that provides health care services for certain low-income persons and certain aged, blind or disabled individuals.
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• Medicaid Reimbursement Initiative/Gap Assessment Program (MRI/GAP Plan)
  A plan designed to supplement losses incurred on providing care to Medicaid and uninsured patients.
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• Medical Board
  The entity that licenses physicians to practice in North Carolina and disciplines those who violate state law and rules related to medical practice. www.ncmedboard.org
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• Medical Consumer Price Index
  An inflationary statistic that measures the cost of all purchased health care services.
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• Medical doctor (MD)
  A licensed physician who is a graduate of an accredited school and practices allopathic medicine.
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• Medical error
  The failure of a planned action to be completed as intended (error of execution) or the use of a wrong plan to achieve an aim (error of planning).
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• Medical Loss Ratio (MLR)
  Cost ratio of total benefits used compared to revenues received.
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• Medical malpractice insurance
  Insurance purchased by a person or entity, such as a doctor or hospital, that pays up to the limits of the policy for damages to a patient caused by malpractice.
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• Medical savings account (MSA)
  A method of financing health care by giving tax advantages to individuals who establish and maintain personal accounts for health care purposes; similar to an Individual Retirement Account for(...)
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• Medical staff
  The licensed physicians and other health care providers credentialed and privileged to provide medical care to patients in a hospital.
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• Medicare
  A federally funded program that pays for medical services to residents over age 65 and the permanently disabled. Coverage is divided into two components.
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• Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
  Bipartisan federal legislation signed into law on April 16, 2015 that repealed the physician sustainable growth rate (SGR) formula and encouraged the adoption of “alternative payment mechanisms.”
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• Medicare Administrative Contractor (MAC)
  Replaces Medicare Part A Fiscal Intermediaries (FIs) and Part B Carriers with 15 new regional Medicare provider bill payment and cost report intermediaries. North Carolina is in MAC Region 11 (J11).
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• Medicare Advantage
  Also referred to as “Medicare Part C,” or “Medicare+Choice,” a Medicare program under which eligible Medicare enrollees can elect to receive benefits through a managed care program that places(...)
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• Medicare Advantage Plan
  Sometimes called “Part C” or “MA Plans,” are offered by private companies approved by Medicare. Medicare pays these companies to cover your Medicare benefits.
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• Medicare Cost Reports
  Reports submitted by hospitals that provide services to Medicare beneficiaries. These reports are a condition of participation in the program and contain detailed hospital data, including(...)
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• Medicare Dependent
  A Medicare reimbursement category for a hospital that is located in a rural area, has no more than 100 beds, and has had at least 60 percent of its inpatient days or discharges attributed to Medicare.
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• Medicare Modernization Act of 2003 (MMA)
  A federal law that provided a prescription drug benefit under the Medicare program. MMA made various other adjustments to the Medicare and Medicaid programs affecting providers, including(...)
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• Medicare Part A
  One of two parts of the Medicare program that covers inpatient hospital services and services furnished by other health care providers such as nursing homes, home health agencies, and hospices.(...)
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• Medicare Part B
  One of two parts of the Medicare program that covers outpatient, physician, and medical supplier services. Part B coverage is optional and must be paid for separately through monthly premium payments.
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• Medicare Part C
  A Medicare program under which eligible Medicare enrollees can elect to receive benefits through a managed care program that places providers at risk for those benefits.
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• Medicare Part D
  The part of the Medicare program that covers prescription drug coverage. Since 2006, beneficiaries have had access to partial prescription drug coverage paid mainly through state payments,(...)
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• Medicare Payment Advisory Commission (MedPAC)
  A non-partisan congressional advisory body charged with providing policy advice and technical assistance concerning the Medicare program and other aspects of the health system. It conducts(...)
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• Medicare Rural Hospital Flexibility (Flex) Program
  A program created by Congress in 1997 that allows small hospitals to be certified as Critical Access Hospitals (CAHs) and offers grants to States to help implement initiatives to strengthen the(...)
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• Medicare Summary Notice (MSN)
  A notice that people with original Medicare get in the mail every 3 months for their Medicare Part A and Part B-covered services. If you don’t get any services or medical supplies during that(...)
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• Medigap
  A policy guaranteeing to pay a Medicare beneficiary’s co- insurance, deductible, and co-payments and provide additional health plan or non-Medicare coverage for services up to a predefined(...)
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• Merit-based Incentive Payment System (MIPS)
  A new payment mechanism that will provide annual updates to physicians starting in 2019, based on performance in four categories: quality, resource use, clinical practice improvement activities(...)
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• Methicillin Resistant Staphylococcus Aureus (MRSA)
  A type of staph infection that is resistant to certain antibiotics including methicillin and other more common antibiotics such as oxacillin, penicillin and amoxicillin. MRSA is a hospital-(...)
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• Metropolitan Statistical Area (MSA)
  A geographical region with a relatively high population density at its core and close economic ties throughout the area.
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• Midlevel Practitioner (MLP)
  Nurse practitioners, certified nurse-midwives and physicians’ assistants who have been trained to provide medical services that otherwise might be performed by a physician. Midlevel(...)
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• Morbidity
  Incidents of illness and accidents in a defined group of individuals.
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• Mortality
  Incidents of death in a defined group of individuals.
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• n

• National Cancer Registry
  A unit within the National Institutes of Health (NIH) that provides updates on the latest cancer diseases, research and diagnosis. www.ncri.ie
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• National Center for Health Statistics (NCHS)
  A division within the U.S. Department of Health and Human Services that is responsible for gathering data on illness and disability, producing the vital statistics of the nation and tracking the(...)
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• National Committee for Quality Assurance (NCQA)
  A nonprofit organization created to improve patient care quality and health plan performance in partnership with managed care plans, purchasers, consumers, and the public sector.(...)
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• National Drug Code (NDC)
  Classification system for drug identification, similar to UPC code.
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• National Incident Management System (NIMS)
  A standardized approach to incident management and response that establishes a uniform set of processes and procedures that emergency responders at all levels of government use to conduct(...)
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• National Information Center on Health Services Research and Health Care Technology (NICHSR)
  A division within the U.S. Department of Health and Human Services that supports analyses and evaluations of the health care system and its financing, and underwrites the development and testing(...)
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• National Institutes of Health (NIH)
  A division within the U.S. Department of Health and Human Services that is responsible for most of the agency's medical research programs. www.nih.gov
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• National Provider Identifier (NPI)
  The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the(...)
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• National Quality Forum (NQF)
  A not-for-profit membership organization created to develop and implement a national strategy for health care quality measurement and reporting.  www.qualityforum.org
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• National Rural Health Association (NRHA)
  A national trade association representing rural hospitals, rural health clinics and other rural health care providers. www.ruralhealthweb.org/
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• NC Division of Services For The Deaf And Hard of Hearing (DSDHH)
  Part of the NC Department of Health and Human Services.
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• NC Hospital Foundation (NCHF)
  The 501(c)(3) affiliate of the NC Healthcare Association. Established in 1961, the Foundation supports the Association’s work in quality improvement, rural healthcare and education.
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• NC Telehealth Network (NCTN)
  The NC Telehealth Network (NCTN) provides high-speed, reliable, and cost-efficient broadband services with large discounts to eligible public and non-profit health care providers in North(...)
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• NCHA Strategic Partners
  NCHA Strategic Partners is a wholly owned subsidiary of the NC Healthcare Association and is committed to being the first resource healthcare providers turn to for access to cost-effective(...)
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• Neonatal Intensive Care Unit (NICU)
  A hospital unit with special equipment for the care of premature and seriously ill newborn infants.
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• Network
  A group of hospitals, physicians, other providers, insurers, and/or community agencies that work together to coordinate and deliver a broad spectrum of services to their community.
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• Never event
  An event that results in death, loss of a body part, disability, or loss of bodily function lasting more than seven days or still present at the time of discharge from an inpatient health care(...)
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• Newborn (NB)
  A child under 28 days of age.
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• Nonprofit Hospital
  A non-taxable hospital that operates on a not-for-profit basis under the ownership and control of a private corporation. Usually owned by a community, church or other organization concerned with(...)
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• North Carolina Center for Rural Health Innovation and Performance
  The NC Center for Rural Health was created by the North Carolina Healthcare Association in 1996 as a rural health resource center, providing expert technical assistance and professional(...)
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• North Carolina Healthcare Association (NCHA)
  The North Carolina Healthcare Association is statewide trade association representing more than 130 hospitals and health systems. The association promotes improved delivery of quality healthcare(...)
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• North Carolina Hospital Quality Performance Report
  The NC Quality Center's web-based transparent, hospital-specific performance report for North Carolinians. www.NCHospitalQuality.org/
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• North Carolina Institute of Medicine (NCIOM)
  The NC Institute of Medicine seeks constructive solutions to statewide problems that impede the improvement of health and efficient and effective delivery of healthcare for all North Carolina(...)
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• North Carolina Office of Emergency Management Services (NC OMES)
  The mission of the Office of Emergency Medical Services is to foster emergency medical systems, trauma systems and credentialed EMS personnel to improve in providing responses to emergencies and(...)
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• North Carolina Prevention Partners (NCPP)
  NC Prevention Partners is a state and national leader in guiding schools, hospitals and workplaces to improve their culture of wellness by improving policies and environments that address(...)
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• North Carolina-Virginia Hospital Engagement Network (NoCVA)
  The North Carolina-Virginia Hospital Engagement Network (NoCVA HEN) is a group of 117 hospitals in North Carolina and Virginia working to meet the goals of the Partnership for Patients, a(...)
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• Nosocomial infections
  An infection acquired by an individual while receiving care or services in a health care organization.
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• Do not resuscitate (DNR)
  An advance directive that patients may make to forego cardiopulmonary resuscitation or other resuscitative efforts. (See advance directive.)
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• Notice of Proposed Rule-making (NPRM)
  A public notice issued by law when one of the independent agencies of the United States government wishes to add, remove, or change a rule or regulation as part of the rule-making process.
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• Nuclear Regulatory Commission (NRC)
  A federal commission created in 1974 to protect the public health and safety by regulating civilian uses of nuclear materials. www.nrc.gov
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• Nurse Anesthetist
  A registered nurse who is qualified by special training to administer anesthesia in collaboration with a physician or dentist and who can assist in the care of patients who are in critical condition.
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• Nurse Midwife
  A registered nurse that has received special training to examine expectant mothers and perform or assist in routine labor and delivery of normal infants.
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• Nurse Practitioner (NP)
  A registered nurse who has completed additional training beyond basic nursing education and provides primary health care services in accordance with state nurse practice laws or statutes. Nurse(...)
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• Nursing quality indicators
  A set of 10 nursing-sensitive indicators that link nursing interventions to patient outcomes.
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• o

• Obstetrician-gynecologist (OB-GYN)
  A physician who specializes in women’s health.
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• Occupational Safety and Health Administration (OSHA)
  A federal agency within the U.S. Department of Labor that is responsible for setting standards to promote and enforce employee safety in the workplace. www.osha.gov
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• Occupational therapist (OT)
  A health care professional in rehabilitation who helps patients regain, develop and build skills for independent functioning.
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• Office of Inspector General (OIG)
  The enforcement arm within the U.S. Department of Health and Human Services (HHS) that oversees investigations of alleged violations of Medicare and Medicaid laws and rules. (Most federal(...)
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• Office of Management and Budget (OMB)
  A federal agency responsible for providing fiscal accounting and budgeting services for the federal government. www.whitehouse.gov/omb
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• Office of Professional Standard Review Organizations
  The health standards and quality bureau of the Centers for Medicare and Medicaid Services.
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• Office of the Assistant Secretary for Preparedness and Response (ASPR)
  The federal agency within the U.S. Department of Health and Human Services (HHS) that provides health care preparedness grants. www.hhs.gov/aspr
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• Office of the National Coordinator for Health Information Technology (ONC)
  ONC is the principal federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health(...)
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• Omnibus Budget Reconciliation Act (OBRA)
  An amendment to the federal budget that outlines new federally funded programs or revisions to existing programs.
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• Operating Margin
  Operating margins reflect a surplus or deficit from operations. Through predominantly nonprofit in Michigan, hospitals need positive margins to replace old equipment, recruit and retain(...)
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• Operating Room (OR)
  Hospital suite in which surgery requiring anesthesia is performed.
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• Optional Medicaid eligibility groups
  Sub-sets of the population for whom the Federal government will provide the Federal Medical Assistance Percentage (FMAP) of coverage.
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• Optional Medicaid services
  Medical services, outside of the mandatory services prescribed by the Federal government, for which the Federal government will provide the Federal Medical Assistance Percentage (FMAP) of coverage.
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• Organ procurement organization (OPO)
  A non-profit, federally funded organization that aids in the organ transplantation process.
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• ORYX
  The integration of performance measurement into the Joint Commission’s accreditation process. Each accredited facility must select vendors that have been approved by the Joint Commission for the(...)
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• Osteopathic
  One of two schools of medicine that uses manipulative measures in treating patients in addition to the diagnostic and therapeutic measures of medicine. The other school is allopathic.
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• Otolaryngologist (ENT)
  Physician trained in the medical and surgical management of patients with diseases and disorders of the ear, nose throat (ENT) and related structures of of the head and neck.
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• Out-of-area benefits
  The coverage allowed to HMO members for emergency and other situations outside of the prescribed geographic area of the HMO.
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• Out-of-pocket maximum
  The most an individual will have to pay for covered medical expenses in a plan year through deductible and coinsurance before the insurance plan begins to pay 100 percent of covered medical expenses.
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• Outcome and Assessment Information Set (OASIS)
  A group of data elements that: represent core items of a comprehensive assessment for an adult home care patient; and form the basis for measuring patient outcomes for purposes of outcome-based(...)
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• Outcome measures
  Assessments to gauge the results of treatment for a particular disease or condition. Outcome measures include the patient's perception of restoration of function, quality of life, and functional(...)
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• Outlier
  A patient case that falls outside of the established norm for diagnosis related groups.
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• Outpatient
  A person who receives health care services without being admitted to a hospital.
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• Outpatient
  A patient who receives medical treatment without being admitted to a hospital.
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• Outpatient Prospective Payment System (OPPS)
  A determined payment rate for a Medicaid outpatient procedure regardless of services rendered or the intensity of the services.
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• Over-the-Counter (OTC)
  Medicines sold directly to a consumer without a prescription from a healthcare professional, as opposed to prescription drugs, which may be sold only to consumers possessing a valid prescription.
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• p

• Palliative care
  Care for not only physical symptoms, but also for emotional, social, spiritual, psychological and cultural symptoms to achieve the best possible quality of life. Palliative care is usually(...)
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• Palmetto GBA
  Palmetto GBA, headquartered in Columbia, SC, administers the transaction process for Medicare services in North Carolina. www.palmettogba.com
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• Participating provider
  A health care provider who has a contractual arrangement with a health care service contractor, HMO, PPO, IPA or other managed care organization.
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• Partnership for Patients
  The Partnership for Patients is a public-private partnership that will help improve the quality, safety and affordability of health care for all Americans. With funding provided by the(...)
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• Patient-Centered Care
  Care that is respectful of and responsive to individual patient preferences, needs and values and ensures patient values guide all clinical decisions; care that is coordinated, communicative and(...)
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• Patient Protection and Affordable Care Act (PPACA)
  The Patient Protection and Affordable Care Act, also known as the Affordable Care Act (ACA) or informally referred to as Obamacare, is a United States federal statute signed into law(...)
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• Patient Safety Organization (PSO)
  A PSO collects, aggregates and analyzes patient safety events that are confidentially reported by hospitals and other healthcare providers. By encouraging voluntary and confidential reporting of(...)
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• Patient Self-Determination Act (PSDA)
  A federal law passed by the United States Congress in 1990 that required many hospitals, nursing homes, home health agencies, hospice providers, health maintenance organizations (HMOs), and(...)
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• Pay for performance
  A new movement in health insurance where providers are rewarded for quality of health care services. Also called value-based purchasing.
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• Payer
  An organization (such as the federal government for Medicare or a commercial insurance company) or person who directly reimburses health care providers for their services.
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• Payment
  Reimbursement a hospital receives for care provided; usually less than the standard charge and sometimes less than the cost of providing care.
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• Peer review
  Review of a health professional’s performance of clinical professional activities by peers through formally adopted written procedures.
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• Peer Review Organization or Professional Review Organization (PRO)
  An organization with which the Medicare program and hospitals contract for quality and utilization review of services covered by the program.
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• Per member per month (PMPM)
  The amount of money paid or received on a monthly basis for each individual enrolled in a managed care plan, often referred to as capitation.
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• Performance measure
  A quantitative tool (for example, rate, ratio, index or percentage) that provides an indication of an organization's performance in relation to a specified process or outcome.
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• Physical Therapist (PT)
  An individual trained, licensed in, or practicing physical therapy.
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• Physician Assistant (PA)
  A trained, licensed individual who performs tasks that might otherwise be performed by physicians or under the direction of a supervising physician.
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• Physician-hospital organization (PHO)
  A legal entity formed and owned by one or more hospitals and physician groups in order to obtain payer contracts and to further mutual interests; one type of integrated delivery system.
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• Physician Payment Review Commission (PPRC)
  Established by Congress in 1986 to advise it on reforms of Medicare policies for paying physicians. Submits a report to Congress annually.
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• Point-of-Service Plan (POS)
  A model that combines features of both HMOs and traditional insurance. Enrollees decide at the time care is needed whether to use a doctor who is in the network or one who is not. Copayments and(...)
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• Political action committee (PAC)
  A group of people organized to collect and distribute contributions to political candidates.
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• Pre-admission testing (PAT)
  Patient tests performed on an outpatient basis prior to admission to the hospital.
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• Pre-existing condition
  An illness or other medical condition that a patient has experienced before the effective date of insurance coverage.
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• Preferred provider organization (PPO)
  A panel of physicians, hospitals, and other health care providers of services to an enrolled group for a fixed periodic payment.
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• Prenatal care
  Services to pregnant women designed to ensure that both the expectant mother and the newborn are in the best health. A lack of prenatal care early in the pregnancy is associated with low birth(...)
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• Prescription (Rx)
  An instruction written by a medical practitioner that authorizes a patient to be provided a medicine or treatment.
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• Present on Admission (POA)
  A requirement the Centers for Medicare & Medicaid Services (CMS) has mandated which requires that hospitals report if an infection was present when a patient was admitted to a facility on all(...)
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• Preventive Care
  Comprehensive care emphasizing priorities for prevention, early detection, and early treatment of conditions, generally including routine physical examination, immunization, and well-person care.
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• Primary Care
  Basic health care; a branch of medicine that accentuates the point when a patient first seeks assistance in a health care system and the treatment of simpler, more common illnesses and injuries.
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• Process improvement
  The application of the plan-do-study-act (PDSA) philosophy to processes to produce positive improvement and better meet the needs and expectations of customers.
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• Professional Standards Review Organization (PSRO)
  A physician-sponsored organization charged with reviewing the services provided patients who are covered by Medicare, Medicaid and maternal and child health programs. The purpose of the review(...)
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• Prospective Payment System (PPS)
  A method of financing health care that mandates payments in advance for the provision of services and is based on diagnostic related groups.
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• Provider
  A hospital, physician, group practice, nursing home, pharmacy, or any individual or group of individuals that provides a health care service.
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• Provider Reimbursement Review Board (PRRB)
  A federal board responsible for making decisions regarding provider appeals on Medicare reimbursement issues.
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• Provider-sponsored organization (PSO)
  A provider-owned entity that is certified by the Centers for Medicare and Medicaid Services to participate in the Medicare+Choice program and to assume risk for benefits provided to Medicare(...)
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• Psychiatric Advance Directive
  A legal document that allows a person to outline their treatment preferences and healthcare power of attorney. States that utilize psychiatric advance directives (PAD) at a higher rate have a(...)
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• Public option
  A government-run health-insurance plan that could offer coverage at a cost below that of private insurance plans because of lower administrative costs and possibly lower reimbursements to(...)
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• q

• Qualified Medicare Beneficiary (QMB)
  A program that helps Medicare beneficiaries of modest means pay all or some of Medicare's cost sharing amounts (ie. premiums, deductibles and copayments).
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• Quality assurance
  A formal set of activities to review and improve the quality of services provided. Quality assurance includes quality assessment and corrective actions to remedy any deficiencies identified in(...)
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• Quality Assurance (QA)
  Maintaining a high quality of health care by constantly measuring the effectiveness of the organizations that provide it.
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• Quality Health Indicators (QHI)
  Standardized, evidence-based measures of health care quality that can be used with readily available hospital inpatient administrative data to measure and track clinical performance and outcomes.
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• Quality improvement
  A continuous effort to provide services at the highest level of quality at the lowest level of cost.
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• Quality improvement organization (QIO)
  QIOs hold contracts with CMS to make sure patients get the right care at the right time, particularly among underserved populations. QIOs are directed to ensure that Medicare payment is made(...)
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• Quality Improvement (QI)
  Consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups.
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• r

• Rate-setting
  The determination by a government body of rates a health care provider may charge private-pay patients.
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• Recovery
  In general, recovery for behavioral health diagnoses means improvement of health, well-being, and learning to manage one’s symptoms and diagnosis. Recovery is different for everyone and not(...)
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• Recovery Audit Contractors (RAC)
  Recovery audit contractors review old Medicare claims to discover overpayments and underpayments. RACs are paid on the basis of a percentage of the overpayments they recover.
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• Referring Physician
  A physician who sends a patient to another source for examination, surgery, or to have specific procedures performed, usually because the referring physician cannot adequately provide the needed(...)
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• Refined diagnosis related group (RDRG)
  An expanded list of diagnosis related groups to take into account a patient's severity of illness.
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• Regional Advisory Committees (RACs)
  Each county and hospital in NC is currently included in at least one of seven Regional Advisory Committees. RACs were initially established for the purpose of regional trauma planning, to(...)
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• Registered Nurse (RN)
  One who has graduated from a college or university program of nursing education and has been licensed by the state.
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• Reinsurance
  A type of insurance purchased by primary insurers from secondary insurers. A commercial or captive insurance company purchases reinsurance to protect against part or all losses the primary(...)
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• Relative Value Scale (RVS)
  An index assigning various weights to various medical services. Each weight represents a relative amount to be paid for each service. The RVS used in the development of the Medicare Fee Schedule(...)
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• Relative Value Unit (RVU)
  The unit of measure for a relative value scale. RVUs must be multiplied by a dollar conversion factor to become payment amounts.
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• Rescission
  Insurance companies' practice of dropping patients after they file expensive claims, on the grounds that applicants misrepresented their health history when they signed up for coverage.
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• Resource-Based Relative Value Scale (RBRVS)
  Medicare fee schedule for physician services that sets a uniform payment in each geographic area for most of the approximately 7,000 medical procedures.
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• Resource Utilization Group (RUG)
  A classification for nursing home patients whose resident information is similar and who have a certain per diem reimbursement rate.
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• Return on investment (ROI)
  A measure of a company’s ability to use its assets to generate additional value for shareholders. It is calculated as net profit divided by net worth and is expressed as a percentage.
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• Risk
  The chance or possibility of loss. Also used to refer to the insured or to the property coverage by a policy. Risk is also defined in health insurance terms as the possibility of loss associated(...)
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• Risk classification
  The process by which a company decides how its premium rates should differ according to the risk characteristics of individual insureds.
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• Risk management
  The practice of identifying and analyzing loss exposures and taking steps to minimize the financial impact of the risks they impose.
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• Root cause
  The most fundamental reason for the failure or inefficiency of a process. Also called underlying cause.
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• Root Cause Analysis (RCA)
  A process for identifying the basic or causal factor(s) that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event.
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• Rural Health Clinic (RHC)
  A health care organization that is in compliance with the federal Rural Health Clinics Act. RHCs must be located in a medically underserved area or a health professions shortage area, use(...)
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• Rural Referral Center
  Hospitals located in rural areas that meet certain criteria to be paid the Medicare prospective payment system’s urban rate, adjusted by the rural wage index. Qualifying criteria include such(...)
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• s

• Safe Practices
  Practices that reduce the risk of harm from the processes, practices or systems of healthcare, the standardization of which is likely to have significant benefit for patient safety if fully(...)
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• Safety net providers
  Providers who have a mission or mandate to deliver large amounts of care to uninsured or other vulnerable patients (e.g., public hospitals, teaching hospitals, community health centers or clinics).
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• Satisfaction Measures
  Measures that address the extent to which the patients/enrollees, practitioners and/or purchasers perceive their needs to be met.
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• Schedule H
  A special section of IRS Form 990 for nonprofit entities that is required to be completed by hospitals, providing details on community benefit and other activities.
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• Securities and Exchange Commission (SEC)
  An independent agency of the United States federal government. The SEC holds primary responsibility for enforcing the federal securities laws, proposing securities rules, and regulating the(...)
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• Sentinel event
  An unexpected occurrence involving death or serious physical or psychological injury, or the risk, thereof.
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• Service Area
  The geographical area in which a managed care plan is licensed to provide health care services to its members; or the region served by a hospital or other health care provider.
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• Severity Adjustment
  Classification of patients by severity-of-illness data to allow for meaningful comparison of performance and quality among organizations and practitioners.
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• Single payer
  A system in which a government insures all its citizens, paid for by tax dollars. It is used by Britain and Canada.
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• Single Photon Emission Computed Tomography (SPECT)
  A nuclear medicine tomographic imaging technique using gamma rays.
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• Skilled nursing facility (SNF)
  A facility, either freestanding or part of a hospital, that accepts patients in need of rehabilitation and medical care that is of a lesser intensity than that received in the acute care setting(...)
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• Social Security Administration (SSA)
  An independent agency of the U.S. federal government that administers Social Security, a social insurance program consisting of retirement, disability, and survivors' benefits.
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• Sole Community Hospital (SCH)
  A Hospital is eligible to be classified as a Sole Community Hospital if it is located more than 35 miles from other like hospitals.
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• Sole Community Provider
  Health care facility located in an isolated area that serves as the only source of emergency, outpatient, and inpatient care in the region. These facilities receive a special designation from(...)
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• Special Operations Response Team
  SORT is a private non-profit organization located in Winston-Salem, is a federally supported disaster medical team that responds nationwide.
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• Specialty hospital
  A limited-service hospital designed to provide one medical specialty such as orthopedic or cardiac care.
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• Speech Therapy
  Training to help people with speech and language problems to speak more clearly.
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• Stark II
  The commonly used name for federal laws and regulations that ban physician referral to entities with which the physician has a financial relationship.
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• State Children’s Health Insurance Program (SCHIP)
  See "Children’s Health Insurance Program (CHIP)"
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• State fiscal year
  The state government's accounting year, which begins July 1 and ends June 30.
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• State Health Coordinating Council (SHCC)
  Directs the development of the annual State Medical Facilities Plan (SMFP).  Aims to promote cost-effective approaches, expand health care services to the medically underserved, and encourage(...)
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• State Medical Facilities Plan (SMFP)
  An annual document that contains policies/methodologies used in determining need for new health care facilities and services.
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• State share
  The cost, based on the state’s per capita income, of the Medicaid program less the Federal Medical Assistance Percentage (FMAP) and any applicable block grants.
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• Stop loss
  The point at which a third party has reinsurance to protect against the overly large single claim or the excessively high aggregate claim during a given period of time. Large employers that(...)
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• Subacute care
  Care given to patients who require less than a 30-day length of stay in a hospital and who have a more stable condition than those receiving acute care.
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• Subsidies
  In the context of health-care reform, these are financial credits from the government that are distributed to Americans — calculated based on income — that Americans could use to purchase health(...)
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• Sudden Infant Death Syndrome (SIDS)
  Also known as cot death or crib death, is the sudden unexplained death of a child less than one year of age.
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• Supplemental medical insurance
  Private health insurance, also called medigap insurance, designed to supplement Medicare benefits by covering certain health care costs that are not paid for by the Medicare program.
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• Supplemental Security Income (SSI)
  A federal program of income support for low income, aged, blind and disabled persons established by Title XVI of the Social Security Act. Qualification for SSI often is used to establish(...)
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• Surgical Site Infection (SSI)
  An infection that occurs after surgery in the part of the body where the surgery took place.
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• Sustainable Growth Rate (SGR)
  A method used by the Centers for Medicare and Medicaid Services (CMS) in the United States to control spending by Medicare on physician services.
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• Swing Bed Providers
  The Social Security Act permits certain small, rural hospitals to enter into a swing bed agreement, under which the hospital can use its beds, as needed, to provide either acute or skilled(...)
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• Swing beds
  Acute care hospital beds that can also be used for a different level of care.
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• System error
  An error that is not the result of an individual's action, but the predictable outcome of a series of actions and factors that comprise a diagnostic or treatment process.
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• t

• Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)
  A federal law that authorizes health plans to enter into arrangements with the Centers for Medicare & Medicaid Services for cost and risk contracts.
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• Teaching hospital
  A hospital that has an accredited medical residency training program and is typically affiliated with a medical school.
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• Telemedicine
  Health care consultation and education using telecommunication networks to transmit information.
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• Temporary Assistance for Needy Families (TANF)
  A federal assistance program that provides cash assistance to indigent American families through the United States Department of Health and Human Services.
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• Temporary Total Disability (TTD)
  An injury that does not result in death or permanent disability, but makes the injured person unable to perform regular duties or activities.
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• Tertiary care
  Highly specialized care given to patients who are in danger of disability or death.
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• Duke Endowment, The
  The Duke Endowment seeks to fulfill the legacy of James B. Duke by improving lives and communities in the Carolinas through higher education, health care, rural churches and children’s services.(...)
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• The Joint Commission
  Founded in 1951 by doctors and hospitals, The Joint Commission (formerly Joint Commission on Accreditation of Healthcare Organizations or JCAHO) evaluates and accredits health care organizations(...)
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• The Joint Commission (formerly Joint Commission on Accreditation of Healthcare Organizations)
  Formerly called JCAHO, or Joint Commission on Accreditation of Hospitals, this is the peer review organization which provides the primary review of hospitals and healthcare providers. Many(...)
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• Third-party administrator
  A person or organization that manages the payment, processing, and settlement of life, health, dental, disability, and self-funded insurance claims for another person or organization.
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• Third Party Administrator (TPA)
  An independent organization that provides administrative services including claims processing and underwriting for other entities, such as insurance companies or employers.
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• TITLE XIX
  A section of the U.S. Social Security Act that authorizes and details the parameters of the Medicaid Program.
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• TITLE XVIII
  A section of the U.S. Social Security Act that authorizes and details the parameters of the Medicare Program.
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• TITLE XXI
  A section of the U.S. Social Security Act that establishes the Children’s Health Insurance Program (CHIP).
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• Tort
  A negligent or intentional civil wrong not arising out of a contract or statute that injures someone in some way and for which the injured person may sue the wrongdoer for damages.
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• Total margin
  The ratio of total revenue to total costs or expenses, including non-patient care.
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• Transparency
  A movement toward providing more information to the public on hospital operation costs and quality.
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• Trauma center
  Trauma center verification is the process by which the American College of Surgeons confirms that a hospital is performing as a trauma center and meets the criteria contained in the ACS(...)
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• Traumatic Brian Injury (TBI)
  A non-degenerative, non-congenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial(...)
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• Triage
  The process by which patients are sorted or classified according to the type and urgency of their conditions.
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• TRICARE
  A program that pays for care delivered by civilian health providers to retired members and dependents of active and retired members of the seven uniformed services of the United States.
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• TRICARE
  Formerly known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), is a health care program of the United States Department of Defense Military Health System.[1](...)
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• u

• U.S. Department of Health and Human Services (HHS)
  A department within the executive branch of the federal government responsible for Social Security and federal health programs in the civilian sector. www.dhhs.gov
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• U.S. House Committee on Ways and Means
  A congressional committee with primary oversight of Medicare, Social Security and other public welfare programs. Also responsible for legislation concerning taxes, bonded debt and(...)
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• U.S. House Energy and Commerce Committee
  A congressional committee whose primary jurisdiction includes most hospital- and health care-related issues. Members of this committee have significant influence over the development of federal(...)
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• U.S. Per Capita Cost (USPCC)
  The national average cost per Medicare beneficiary, calculated annually by HCFA’s Office of the Actuary.
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• U.S. Senate Committee on Finance
  A congressional committee dealing with Medicare, Medicaid, federal bonds, the customs service and related issues, public moneys, revenue sharing, health programs funded by specific taxes,(...)
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• U.S Senate, Health Education, Labor, and Pensions Committee (HELP)
  A congressional committee whose primary jurisdiction includes most hospital- and health care-related issues. Members of this committee have significant influence over the development of federal(...)
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• Uncompensated care
  All health care services for which a provider is not compensated, including bad debt, charity care, and other services that go unpaid. (See "charity care")
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• Underinsured
  People with some type of health insurance but not enough to cover all their health care needs.
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• Underlying cause
  The most fundamental reason for the failure or inefficiency of a process. Also called root cause.
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• Uniform Billing Code of 1992 (UB-92)
  Bill form used to submit hospital insurance claims for payment by third parties. Similar to HCFA 1500, but reserved for the inpatient component of health services.
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• Uniform Billing Code of 2004 (UB-04)
  A federal directive requiring a hospital to follow specific billing procedures, itemizing all services included and billed for on each invoice.
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• Uniform hospital discharge data set
  A defined set of data that gives a minimum description of a hospital discharge. It includes data on age, sex, race, residence of patient, length of stay, diagnosis, physicians, procedures,(...)
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• Uninsured
  People who lack health insurance of any kind.
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• Unique Device Identifier (UDI)
  A UDI is a unique numeric or alphanumeric code that consists of two parts: a device identifier (DI), a mandatory, fixed portion of a UDI that identifies the labeler and the specific version or(...)
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• Unpreventable Adverse Event
  An adverse event resulting from a complication that cannot be prevented given the current state of knowledge.
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• Upper Payment Limit (UPL)
  The maximum amount states can pay providers for Medicaid services.
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• Urgent care
  Medical care for illness or injury requiring attention at a level higher than for a physician office visit but less than the level of emergency care.
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• Usual, customary and reasonable charges (UCR)
  Charges for health care services in a geographical area that are consistent with the charges of identical or similar providers in the same geographic area.
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• Utilization
  The patterns of use of a service or type of service within a specified time, usually expressed in a rate per unit of population- at-risk for a given period (e.g., the number of hospital(...)
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• Utilization review (UR)
  An evaluation of the necessity and appropriateness of the use of health care services, procedures, and facilities.
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• v

• Value-based purchasing (VBP)
  A purchasing program designed to transform Medicare from a passive payer of claims to an active purchaser of care. These programs make a portion of the hospital payment contingent on actual(...)
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• Ventilator Associated Pneumonia (VAP)
  A sub-type of hospital-acquired pneumonia (HAP) which occurs in people who are on mechanical ventilation through an endotracheal or tracheotomy tube.
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• Veterans Affairs (VA)
  A federal Cabinet-level agency that provides near-comprehensive healthcare services to eligible military veterans at VA medical centers and outpatient clinics located throughout the country;(...)
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• Vocational Rehabilitation (VR)
  A process which enables persons with functional, psychological, developmental, cognitive and emotional impairments or health disabilities to overcome barriers to accessing, maintaining or(...)
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• w

• Wage index
  A factor used to adjust the base Medicare reimbursement rates for an area to account for geographic differences in wages paid to health care workers.
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• Weapon of mass destruction
  Weapons capable of inflicting mass casualties and destruction; including nuclear, biological and chemical weapons or the means to deliver them.
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• Well-baby care
  Services provided in the first year of a newborn's life to identify, treat, and prevent health care problems.
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• Women, Infants and Children Program (WIC)
  The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides Federal grants to States for supplemental foods, health care referrals, and nutrition education for(...)
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• Workers’ Compensation (WC)
  Provides state-mandated insurance coverage for work-related injuries and disabilities.
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• World Health Organization (WHO)
  A specialized agency of the United Nations generally concerned with health and health care.
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• y

• Year to Date (YTD)
  A period, starting from the beginning of the current year (either the calendar year or fiscal year) and continuing up to the present day.
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• z

• Zone Program Integrity Contractor (ZPIC)
  An entity established in the United States by the Centers for Medicare & Medicaid Services (CMS) to combat fraud, waste and abuse in the Medicare program.
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