- Industry: Health care
- Number of terms: 4240
- Number of blossaries: 0
- Company Profile:
The Blue Cross Blue Shield Association (BCBSA) is a federation of 39 separate health insurance organizations and companies in the United States. Combined, they directly or indirectly provide health insurance to over 100 million Americans.
A method used by MCOs of determining provider reimbursement that assigns a weighted value to each medical procedure or service. To determine the amount the MCO will pay to the physician, the weighted value is multiplied by a money multiplier. Also known as relative value of services.
Industry:Health care
A process by which an MCO uses information about a plan member's health status, personal and family health history, and health-related behaviors to predict the member's likelihood of experiencing specific illnesses or injuries. Also known as health risk appraisal.
Industry:Health care
According to the National Association of Insurance Commissioners' Quality Assessment and Improvement Model Act, managed care plans that require covered persons to use participating providers.
Industry:Health care
The process by which an underwriter reviews each year all the selection factors that were considered when the contract was issued, then compares the group's actual utilization rates to those the MCO predicted to determine the group's renewal rate.
Industry:Health care
According to the Institute of Medicine, "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."
Industry:Health care
Documentation errors in which a treatment is miscoded or the codes used to describe procedures do not match those used to identify the diagnosis.
Industry:Health care
Estimates of money that an insurer needs to pay future business obligations.
Industry:Health care
A patient whose condition requires large financial expenditures or significant human and technological resources.
Industry:Health care
A provision in a member's coverage that limits the amount of coverage by the plan to a certain percentage, commonly 80 percent. Any additional costs are paid by the member out of pocket.
Industry:Health care
A method used by MCOs of determining provider reimbursement that attempts to take into account, when assigning a weighted value to medical procedures or services, all resources that physicians use in providing care to patients, including physical or procedural, educational, mental (cognitive), and financial resources.
Industry:Health care
