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Continued-Stay Review: Assessment of the need for continued inpatient care for a hospitalized patient.

Cost-Sharing: The share of health expenses that a beneficiary must pay, including the deductibles, copayments, coinsurance, and extra bill.

Criteria: Bases for assessing the necessity or appropriateness of a medical service; explicit criteria are written.

Current Procedural Terminology (CPT): A listing of descriptive terms and identifying codes for reporting physician services and procedures.

Deductible: The amount of medical expense that must be incurred and paid by an individual before a third party will assume any liability for payment of benefits.

Discharge Planning: The process of ensuring that patients are discharged as soon as medically appropriate, with follow-up care planned and arranged as needed.

E

Effectiveness: Probability of benefit to patients from a specific medical service under average conditions of use.

Efficacy: Probability of benefit to patients from a specific medical service under ideal conditions of use.

Efficiency: Level of benefit from a fixed level of input or amount of input cost to achieve a defined level of benefit.

Encounter: In the health maintenance organization setting, generally refers to an outpatient visit to a physician or allied health professional.

Enrollee: Individual covered by a health benefit plan.

F

Feedback Approaches: Programs in which physicians' patient care decisions are reviewed based on medical records, claims, or other documents of care, with the results shared with the physician.

Fee-for-Service: A method of paying practitioners on a service-by-service rather than a salaried or capitated basis.

G

Gatekeeper: Primary care provider who is responsible for coordinating all medical treatment rendered to an enrollee of a health plan.

Group Model Health Maintenance Organization: A health maintenance organization that contracts with a primary care or multispecialty medical practice for delivery of health services.

H

Health Maintenance Organization (HMO): An entity that accepts responsibility and financial risk for providing specified services to a defined population during a defined period of time at a fixed price.

High-Cost Case Management: A process for identifying high-cost patients and facilitating the development and implementation of less costly appropriate courses of care.



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