Glossary

Under HIPAA, this is the specific instructions for implementing a standard.

A plan for measurable process or outcome improvement. The plan is usually developed cooperatively by a provider and the Network. The plan must address how and when its results will be measured.

What you pay out-of-pocket for services and care for participating providers and services through your health plan. An in-network copayment is a fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health plan. In-network copayments usually are less than out-of-network copayments. An in-network coinsurance is your share (for example, 20%) of the allowed amount for covered health care services. Your share is usually lower for in-network covered services.

A provider who has a contract with your plan who has agreed to provide services to members of a plan. You will pay less if you see a provider in the network. In-network providers may also be called "preferred provider" or "participating provider."

Utilization of services that are in excess of a beneficiary's medical needs and condition (overutilization) or receiving a capitated Medicare payment and failing to provide services to meet a beneficiary's medical needs and condition (underutilization).

The frequency of new occurrences of a condition within a defined time interval. The incidence rate is the number of new cases of specific disease divided by the number of people in a population over a specified period of time, usually one year.

The ratio of income from tax revenues on an incurred basis (payroll tax contributions and income from the taxation of OASDI benefits) to the HI taxable payroll for the year.

The costs based on when the service was performed rather than when the payment was made.

A freestanding clinical laboratory meeting conditions for participation in the Medicare program and billing through a carrier.
A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's office.

A key clinical value or quality characteristic used to measure, over time, the performance, processes, and outcomes of an organization or some component of health care delivery.