Rekova Health AI Glossary rekovahealth.ai →

Healthcare Data Glossary

838 terms covering Medicare Advantage, Medicaid, ACA, risk adjustment, and more.

Curated by Richard Lieberman · Rekova Health AI

3 8 A B C D E F G H I J L M N O P Q R S T U V W X Z

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A

Abuse Accountable Care Learning Collaborative Accountable Care Organization(ACO)Accountable unit Accredited Standards Committee(ASC)Acknowledgments(EDI)ACO REACH(ACO REACH)Activities of Daily Living(ADL)Actuarial Equivalence Actuarial Value(AV)Acute care - VA Medical Center(AV)Acute care hospital Administrative Loss Ratio(ALR)Administrative Services Only(ASO)Advanced Medical Home(AMH)Advanced Practice Nurse(APRN)Advanced Premium Tax Credit(APTC)Adverse Benefit Determination Adverse Selection Affordable Care Act(ACA)Age Dependency Ratio Aged, Blind, and Disabled(ABD)All Patient Refined Diagnosis Related Group(APR-DRG)Allowable Rating Factor(ARF)Allowed Amount Allowed Claims All-Payer Claims Database(APCD)Alternative Payment Model(APM)Alternative Submission Methodology(ASM)Ambulatory Payment Classifications(APC)American Community Survey(ACS)American Hospital Association(AHA)American National Standards Institute(ANSI)American Recovery and Reinvestment Act of 2009(ARRA)Annual Election Period(AEP)Annual Wellness Visit(AWV)ANSI ASC X12N 837P Accredited Standards Committee X12(ASC X12)ANSI Codes(spatial)Appeal Application Programming Interface(API)Area Deprivation Index Area Health Resources Files Artificial Intelligence(AI)ASA physical status classification ASC X12(EDI)ASC X12 270: Eligibility, Coverage or Benefit Inquiry ASC X12 271: Eligibility, Coverage or Benefit Information ASC X12 275: Additional Information to Support a Health Care Claim Services ASC X12 276 Health Care Claim Status Request(EDI)ASC X12 277 – Health Care Information Status Notification(EDI)ASC X12 277CA Health Care Claim Acknowledgment(EDI)ASC X12 277RFI: Health Care Request for Additional Information(EDI)ASC X12 277U: Health Care Payer Unsolicited Claim Status(EDI)ASC X12 278 - Health Care Services Review Information(EDI)ASC X12 820 - Payment Order & Remittance Advice(EDI)ASC X12 834 - Benefit Enrollment and Maintenance(EDI)ASC X12 835 – Health Care Claim Payment/Advice(EDI)ASC X12 837: Health Care Claim Transaction ASC X12 837I – Health Care Claim Institutional(EDI)ASC X12 837P(EDI)ASC X12 837R – Health Care Services Data Reporting(EDI)ASC X12 997: Functional Acknowledgement ASC X12 999 – Implementation Acknowledgment(EDI)ASC X12 Claim Transaction Life Cycle ASC X12 Transactions(EDI)Attributed Population Attribution Attribution model Authorized Representative Auto-Assignment Automated Call Distribution System Automated Voice Response System(AVRS)Average annual drug costs ACA Marketplaces ACA-Compliant Coverage Accountable Care Organization (ACO)

B

Balanced Budget Act of 1997(BBA97)Base Period Behavioral Health Organization(BHO)Behavioral Health Services Beneficiary Claims Data API(BCDA)Beneficiary with Special Health Care Needs Benefit Period Bill Type Bipartisan Budget Act of 2018 Brand Name Drug Breach(Privacy & Security)Bundled payment Business Associate Business Associate Agreement(BAA)

C

Canonical Representation(CQL)Capitation Cardiac surgery registry Care Coordination Care Management Care Management Care Management Fees CARIN Alliance(EDI)Case Management Case Rate Catastrophic Coverage Categorical Adjustment Index(CAI)Categorically Eligible(Medicaid)Census Block(spatial)Census Block Group(spatial)Census Tract(spatial)Center for Consumer Information & Insurance Oversight(CCIIO)Centers for Medicare & Medicaid Services(CMS)Centers for Medicare & Medicaid Services National Surgical Quality Pilot Certificate(IT)Certified EHR Technology Chart Review Records(CRR)Chief Complaint(Clinical)Children with Special Health Care Needs Children’s Health Insurance Program(CHIP)Children's Hospital Choice Counseling Choose Any Doctor/Any Hospital Chronic Care Management(CCM)Chronic Care Model Chronic Condition Special Needs Plans(C-SNP)Chronic illness Chronic Illness and Disability Payment System(CDPS)Claim Claim Adjudication Claim Adjudication Date Claim Adjustment Reason Code(CARC)Claim Identifier Claim or encounter processing vendor Claims data Clean Claim Clearinghouse Clearinghouse Clinical Classification System Refined(CCSR)Clinical Document Architecture(CDA®)Clinical Drug Clinical Guidelines Clinical Practice Guidelines Clinical Statement Closed Loop Referral CMS Alliance to Modernize Healthcare(CAMH)CMS Healthcare Cost Report File CMS Innovation Center(CMMI)CMS-1500 CMS-HCC COBRA(COBRA)Code of Federal Regulations Code Set Code Set Maintaining Organization(EDI)Cohort Coinsurance Committee on Operating Rules for Information Exchange Community Mental Health Center(CMHC)Community Rating Community-dwelling Medicare Advantage Enrollees Comorbidities Companion Guides(EDI)Companion Guides(EDI)Comprehensive Assessment Comprehensive Primary Care Plus(CPC+)Concept Unique Identifier(CUI)Concurrent Review Concurrent Risk Adjustment Model Condition Category Condition Codes Condition Codes Congressional District Consumer Assessment of Healthcare Providers and Systems(CAHPS)Consumer Operated and Oriented Plan(CO-OP)Consumer Price Index(CPI)Consumer-Directed Health Plan(CDHP)Continuity of Care Document(CCD)Convolutional neural networks(CNN)Coordinated Care Plan(CCP)Coordination of Benefits Copayment Core Based Statistical Area(CBSA)Coronary artery bypass graft(CABG)Cost Plan Cost Sharing Cost Sharing Reduction(CSR)Cost-Sharing Charge Cost-Shifting Council for Affordable Quality Healthcare County County subdivision Coverage Gap Covered Entity Covered Health Care Provider Covered Provider (HIPAA)Credentialing Critical access hospital(CAH)Cultural Competency Current Procedural Terminology(CPT)

E

EDGE Server(EDGE)Elective delivery Electronic Claim Electronic Clinical Quality Measures(eCQMs)Electronic Data Interchange Electronic Health Record(EHR)Electronic Medical Record(EMR)Electronic PHI(Privacy & Security)Emergency Medical Condition Emergency Services Employee Benefits Security Administration(EBSA)Employee Retirement Income Security Act(ERISA)Employer Identification Number(EIN)Employer or Union Retiree Plans Encounter Encounter Data Encounter Data Front-End System(EDFES)Encounter Data Processing System(EDPS)Encounter Data Record(EDR)End Stage Renal Disease(ESRD)Enhanced Alternative Plan Enhanced Medical Home(EMH)Enhanced Primary Care Case Management(EPCCM)Enrollment Broker(EB)Enrollment Duration Enrollment Period Activity Indicator Enterprise Integration Episode of Care Payment Episode payment Episode-Based Bundling Episode-based payment Euclidean distance(STAT)Evidence-based case rate Evidence-Based Medicine Excluded Populations Exempt Population Experience Quality Measures Expression Logical Model(ELM)External Data Gathering Environment(EDGE)External Quality Review Organization

G

Gender Gender Identity Generations Generative adversarial networks(GAN)Generic Drug Gentran(EDI)Geocoding Geographic Cost Factor(GCF)Global bundled payment Global Bundling Global Capitation Global payment Grandfathered Plans(ACA)Grievance Group Health Plan Group Model HMO Group Quarter Population Guaranteed Issue Guidelines

H

Hash(IT)Hazard Ratio(STAT)HCRP Detail Enrollee Report(HCRPDE)HCRP Summary Report(HCRPS)Health and Behavioral Assessment and Intervention Health Benefits Health Care Payment Learning & Action Network(HCP-LAN)Health Care Provider Health Disparities Health Equity Health Equity Index(HEI)Health Homes Health Information Health Information Technology Health Information Technology for Economic and Clinical Health Act(HITECH)Health Information Technology Standards Panel(HITSP)Health Insurance Health Insurance Claim Number Health Insurance Marketplaces Health Insurance Oversight System(HIOS)Health Insurance Oversight System Number Health Insurance Portability and Accountability Act of 1996(HIPAA)Health Level 7(HL7)Health Maintenance Organization(HMO)Health Outcomes Survey(HOS)Health Plan Health Plan Identifier(HPID)Health Savings Account(HSA)Health Spending Health Status Healthcare Common Procedure Coding System(HCPCS)Healthcare Effectiveness Data and Information Set(HEDIS)HHS-operated Risk Adjustment Data Validation(HHS-RADV)Hierarchical Condition Categories(HCC)High-Cost Risk Pool(HCRP)High-Deductible Medigap Policy Highly-Integrated Special Needs Plan(HIDE SNP)HIPAA Administrative Simplification Rules HIPAA Transaction Code Sets(EDI)HIPAA Transactions History of Present Illness(Clinical)HMO-POS(HMO-POS)Home - Community Based Services(HCBS)Household Housing Affordability Index(HAI)

I

ICD-10-PCS Implementation Guide(EDI)Improper Payments Elimination and Recovery Act(IPERA)Inbound File: EDGE Server Enrollment Submission Report(EDGE)Inbound File: EDGE Server Medical Claims Submission Report(EDGE)Inbound File: EDGE Server Pharmacy Claims Submission Report(EDGE)Inbound File: EDGE Server Supplemental Diagnosis File Submission (ESSFS) Report(ESSFS)Incurred But Not Reported Accrual(IBNR)Independent Practice Association(IPA)Independent Review Entity(IRE)Independent Reviewer Index admission Indian Health Care Provider(IHCP)Individual Market Individual Risk Score Individually-Identifiable Health Information Induced Demand Factor(IDF)Inflation Reduction Act of 2022(IRA)In-Home Supportive Services(IHSS)Initial Coverage Election Period(ICEP)Initial Coverage Limit Initial Validation Audit In-network Inpatient hospital services Institute for Advancing Health Value Institute for Mental Disease(IMD)Institutional Special Needs Plan(I-SNP)Instrumental Activities of Daily Living(IADL)Insurance Plan Insurance Product Insurance Risk Insured Integrated Delivery System(IDS)Interactive Voice Response(IVR)Interface Control Document(ICD)International Classification of Diseases Procedure Code System, 10th Revision(ICD-10-PCS)International Classification of Diseases, 10th Revision, Clinical Modification(ICD-10-CM)International Classification of Diseases, Ninth Revision, Clinical Modification(ICD-9-CM)Interoperability

J

JavaScript Object Notation(JSON)

L

Laboratory Laboratory Panel Laboratory Test Legend Drug Liability insurance Limited English Proficient(LEP)Local Care Management Local Codes Logical Observation Identifiers Names and Codes(LOINC)Long Term Service and Supports(LTSS)Long-term care hospital Long-term institutionalized MA enrollees Long-term Institutionalized Status(LTI)Low Bone Mass(Osteoporosis)Low-income Subsidy(LIS)

M

Managed Behavioral Health Organization(MBHO)Managed Care Managed Care Organization(MCO)Managed Care Organization(MCO)Managed Long-Term Care(MLTC)Managed Long-Term Services and Supports(MLTSS)Management Services Organization(MSO)Mandatory Populations MAO-001 Encounter Data Duplicates MAO-002 Encounter Data Processing Status MA-Only Marketing Materials Maximum Out-of-Pocket(MOOP)Measure Sets Measurement Measures Management System(MMS)Medicaid Medicaid 1115 Waiver Medicaid Breast and Cervical Cancer Program(MBCC)Medicaid Encounter Data Medicaid Enterprise System(MES)Medicaid Health Home(Medicaid)Medicaid Managed Care Medicaid Managed Care Medicaid Management Information System(MMIS)Medicaid State Plan Medicaid State Plan Medicaid State Plan Amendment Medicaid Waiver MedicaidRx Medical Claim Medical Home Medical Home Fees Medical imaging(CLINICAL)Medical Loss Ratio(MLR)Medical Savings Account(MSA)Medical Services Organization Medical underwriting Medically Necessary Medicare Access and CHIP Reauthorization Act of 2015(MACRA)Medicare Administrative Contractor(MAC)Medicare Advantage Medicare Advantage Organization(MAO)Medicare Advantage Plan Medicare Advantage Prescription Drug Plan(MA-PD)Medicare Advantage Prescription Drug System(MARx)Medicare Advantage Risk Adjustment Medicare Beneficiary Identifier(MBI)Medicare Cost Plan Medicare FFS Medicare Health and Prescription Drug Plans Medicare Health Plan Medicare Improvements for Patients and Providers Act of 2008 Medicare Medical Savings Account Plan(MSA)Medicare Part A (Hospital Insurance)Medicare Part B (Medical Insurance)Medicare Part B Deductible Medicare Part B Premium Reduction Medicare Part C Medicare Part D(PDP)Medicare Prescription Drug, Improvement, and Modernization Act of 2003(MMA)Medicare Savings Program Medicare Savings Program(MSP)Medicare Secondary Payer(MSP)Medicare Secondary Payer Act Medicare Severity-Diagnosis Related Group(MS-DRG)Medicare Shared Savings Program(MSSP)Medicare Star Ratings(Medicare)Medicare Supplemental Insurance Medicare+Choice(M+C)Medicare-Advantage Medicare-approved Amount Medicare-certified hospital Medication Therapy Management Program(MTM)Medigap Medigap Basic Benefits Medigap Policy Open Enrollment Period(MOEP)Mental Health Parity and Addiction Equity Act of 2008(MHPAEA)Merit-Based Incentive Program System(MIPS)Metal Level Metropolitan Statistical Areas(MSA)Micropolitan Statistical Areas Minimally Disruptive Medicine(MDM)Minimum Data Set(MDS)Model Model of Care Model Output Report(MOR)Modeling Modified Adjusted Gross Income(MAGI)Monthly Membership Report(MMR)Monthly Premium Multimorbidity

O

Obamacare Object Code(IT)Observation stay Odds Ratio(STAT)Ombudsman Program One-sided Risk Ongoing Course of Treatment Open Enrollment Period (Medigap)Operating Rules Optional Supplemental Benefits Ordering Provider Ordering Provider Original Medicare Original Medicare Original Medicare Part A Original Medicare Part B Osteopathic doctor Osteoporosis(Osteoporosis)Outbound File: EDGE Server Detail Medical Claim Error Report(EDGE)Outbound File: EDGE Server Detail Pharmacy Claim Error Report(EDGE)Outbound File: EDGE Server Detail Supplemental Diagnosis File Error Report(EDGE)Outbound File: EDGE Server Enrollee Claim Detail Report(EDGE)Outbound File: EDGE Server Enrollee Claim Summary Report(EDGE)Outbound File: EDGE Server File Accept – Reject Report(EDGE)Outbound File: EDGE Server RA Claim Selection Summary Report(EDGE)Outbound File: EDGE Server RADV Population Summary Statistics Final Report(EDGE)Outbound File: EDGE Server Summary Enrollment Accept – Reject Error Report(EDGE)Outbound File: EDGE Server Summary Medical Claim File Accept – Reject Error Report(EDGE)Outbound File: EDGE Server Summary Supplemental Diagnosis File Accept – Reject Error Report(EDGE)Outcome Outcome Outcome and Assessment Information Set(OASIS)Outcome Quality Measure Outcomes (of health care)Out-of-network Out-of-Pocket Costs Out-of-Pocket Spending Limit Out-of-Pocket Threshold Outpatient hospital care Outpatient Prospective Payment System (OPPS)(OPPS)Overall Star Rating Overpayment Overpayment Rule

P

Package pricing Partial Capitation Partial Dual Eligible Partial Extra Help Participating Provider Patient Patient Centered Medical Home(PCMH)Patient discharge Patient Protection and Affordable Care Act(PPACA)Payer Pay-for-Coordination Pay-for-Performance(P4P)Payment Integrity Information Act of 2019(PIIA)Payment Period Pediatric Accountable Care Organization Demonstration Project Per Member Per Month Percentage(STAT)Percentile(STAT)Performance Measurement Per-Member-Per-Month Personal health Information Personal Representative Pharmacy Claim Pharmacy Network Physician Organization Physician-Hospital Organization (PHO)(PHO)Plan Plan ID(EDGE)Plan Liability Risk Score Plan members who qualify for Extra Help Plan Name Plan of care Plan Sponsor Pneumonia (pneumococcal) vaccination(Clinical)Point-of-Service HMO(POS)Population Population Health Population-Based Payment Model Post Adjudicated Claims Data Reporting(PACDR)Post-stabilization Care Services Potential Member Predictive Analytics Pre-existing conditions Preferred Cost Sharing Pharmacy Preferred Provider Organization(PPO)Pregnancy Management Program Premium Prepaid Health Plan(PHP)Prepaid Inpatient Health Plan (PIHP)(PIHP)Prescription Prescription Drug Category Prescription Drug Hierarchical Condition Categories(RxHCC)Prescription Drug Plan(PDP)Prevention Pricing Method Primary Care Primary Care Case Management(PCCM)Primary Care Provider(PCP)Primary Prevention Primordial Prevention Prior Authorization Privacy Rule Private Fee-for-Service Plan(PFFS)Private Fee-for-Service Plan(PFFS)Private Key/Public Key(IT)Process Quality Measure Processes (of health care)Product Program Integrity(PI)Programs of All-inclusive Care for the Elderly(PACE)Pronouns Proportion of Days Covered(PDC)Protected Health Information(PHI)Provider Provider (For the purposes of credentialing)Provider Contracting Provider Grievance Provider Preventable Conditions(PPC)Provider Taxonomy Provider-preventable conditions(PPC)Psychiatric hospital Public Key Infrastructure(PKI)Purchased Service Provider

Q

Quadruple Aim Qualified Disabled and Working Individuals(QDWI)Qualified Disabled and Working Individuals Program(QDWI)Qualified Electronic Health Record Qualified Health Plan(QHP)Qualified Interpreter Qualified Medicare Beneficiaries with Full Medicaid(QMB+)Qualified Medicare Beneficiaries without other Medicaid(QMB)Qualified Medicare Beneficiary Program(QMB)Qualifying Individuals(QI)Quality Quality assurance Quality Improvement Organization(QIO)Quality of care Quality Vendor(CQL)Quantity Limitation Query(CQL)

R

Rate and Benefits Information System(RBIS)Rate and Benefits Information System(RBIS)Rate Setting Rating Area Ratio(STAT)Readily Accessible Readiness Review Readmissions Rebates Recurrent neural networks(RNN)Referral Referring Provider Registry Rehabilitation hospital Reinsurance Reliability(STAT)Remittance Advice Remark Code(RARC)Rendering Provider REpresentational State Transfer(REST)Repriced Amount Reprocess Required by Law(Privacy & Security)REST API(IT)Retiree Drug Subsidy Program(RDS)Retrieve(CQL)Retrospective Review Reverse Geocoding Review of Systems Reward factor(RF)Rights Rising Risk Risk Adjustment Risk Adjustment Claim Selection Detail Report(RACSD)Risk Adjustment Data Validation Audit(RADV)Risk Adjustment Data Validation Population Summary Statistics Report(RADVPS)Risk Adjustment Data Validation, Medicare Advantage Risk Adjustment Default Charge Risk Adjustment Payment Hierarchical Condition Category Enrollee Report(RAPHCCER)Risk Adjustment Processing System(RAPS)Risk Adjustment Risk Score Detail Report(RARSD)Risk Adjustment Risk Score Summary Report(RARSS)Risk Adjustment Suite of Systems(RASS)Risk Adjustment System(RAS)Risk Adjustment Transfer Elements Extract Report(RATEE)Risk Adjustment User Fee Risk Assessment Period Risk Corridor Risk-Based Managed Care R-Squared Value(STAT)Rural Health Clinic(RHC)Rural Hospital RxNorm

S

Schema(IT)Second Validation Audit Secondary Prevention Secretary(Privacy & Security)Secure Socket Layer(SSL)Secure Socket Layer(SSL)Security Assertion Markup Language(SAML)Security Rule Self-Insured Plan Service Area Service Level Agreement(SLA)Shaping(CQL)Shared Savings Signing(IT)Skilled Nursing Facility(SNF)SOAP Note Social Determinants of Health(SDoH)Social Risk Factors(SRF)Social Security Disability Insurance(SSDI)Society of Actuaries(SOA)Source Code(IT)Special Enrollment Period(SEP)Special Needs Plan(SNP)Special Pharmacy Type Specialty Pharmacy Specified Low - Income Medicare Beneficiary(SLMB)Specified Low-Income Medicare Beneficiaries with full Medicaid(SLMB Plus)Specified Low-Income Medicare Beneficiaries without other Medicaid(SLMB)Sponsor Staff Model HMO Standard Cost Sharing Pharmacy Standards Developing Organization(SDO)State Fiscal Year(SFY)State Innovation Waiver(EDGE)Statistical Significance(STAT)Step Therapy Stop Loss Strong Password(IT)Structural Quality Measure Structure (of health systems or health facilities)Subcontractor(Privacy & Security)Subscriber Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act of 2018(SUPPORT)Sum of Squares(STAT)Summary of Benefits and Coverage(SBC)Summary Rating of Health Plan Quality(MA)Summary Rating of Prescription Drug Plan Quality(MA)Supervising Provider Supplemental Security Income Supplementary Medical Insurance(SMI)Survey of patients’ experiences Survey response rate Sweeps Swing Bed(MA)Symmetric Key(IT)System for Electronic Rate and Form Filings(SERFF)Systematized Nomenclature of Medicine -- Clinical Terms(SNOMED-CT)

U

Uncertainty(CQL)Underwriting Uniform Resource Identifier(URI)Unique Identifier Universal Coverage Unsecured PHI(Privacy & Security)Upside Financial Risk Utilization Management Utilization Review

V

Value(CQL)Value Set(QM)Value Set Authority Center(VSAC)Value-Added Services Value-Based Care(VBC)Value-Based Payment(VBP)Value-Based Payment(VBP)Vendor Very Low Reliability Video Remote Interpreting Virtual Private Network(VPN)

W

Warm transfer Waste Workers’ Compensation Workgroup for Electronic Data Interchange(WEDI)

X

X12(X12)X12 Companion Guides(EDI)X12 Transactions(EDI)X12N(X12N)X12N Implementation Guide(EDI)

Z

ZIP Code ZIP Code Tabulation Areas(ZCTA)ZIP Code Tabulation Areas(ZCTA)