Glossary of Terms
A
A&I (Audits and Investigations). This Branch of the California Department of Health Services performs regular financial and medical audits of CenCal Health and all other Medi-Cal contracted health plans in the State.
ABD (Aged, Blind or Disabled). One of the categories which qualifies a person for Medi-Cal coverage through the SSI program.
ACCESS FOR INFANTS AND MOTHERS PROGRAM (See “AIM”).
ADHC (Adult Day Health Care). A benefit of the Medi-Cal program, under which medical day care is provided to qualifying seniors at a center established for that purpose. CenCal Health does not manage this Medi-Cal benefit.
ADLs (Activities of Daily Living). Basic activities such as dressing, toileting and eating, which are used to determine whether a patient qualifies for specific levels of coverage by Medi-Cal.
ADMHS. Abbreviation for the Santa Barbara County Department of Alcohol, Drug, and Mental Health Services.
ADMISSIONS. Refers to admissions to inpatient facilities (hospitals or nursing facilities).
ADVANCE CARE PLANNING. Consultation and counseling between a Provider and a Member, family member, or legally-recognized decision-maker covering such topics as defining the Member’s goals of care, planning for future intensity of care provided, and defining patient-specific plans for future care, which may be additionally documented in the form of advance directives or a Physician’s Orders for Life-Sustaining Treatment (POLST) Form.
AEVS (Automated Eligibility Verification System). One of several methods offered by EDS to providers to determine if a Medi-Cal patient is eligible, to reduce their SOC (if any), and/or to reserve a Medi-Service for non-SBHI beneficiaries by using the keypad of the user’s telephone.
AFDC (Aid to Families with Dependent Children). State cash assistance program for families and dependent children; Medi-Cal is an automatic benefit when one qualifies for AFDC. AFDC constitutes the largest part of the SBHI Medi-Cal population. Under the federal welfare reform act, it has now been replaced by “CalWorks”.
AID CODE. This code indicates how a person has qualified for the Medi-Cal program; there are nearly 150 such codes.
AIDS (Acquired Immunodeficiency Syndrome). A disease which disables a person’s natural immune system, for which there is currently no cure. Most patients who contract AIDS eventually qualify for Medi-Cal coverage.
AIM (Access for Infants and Mothers). A program, administered by MRMIB, which is funded by premiums paid by members, and State tobacco tax funds, and covers women during their pregnancy. The women are generally the “working poor” — they employed by small employers who have no health insurance, or the dependents of someone so employed. The family income cannot exceed 250% of the FPL, and the person cannot be eligible for Medi-Cal. CenCal Health’s AIM program is called Prenatal PLUS 2.
AIM Linked Infants
Your infant is eligible for automatic enrollment in a health coverage program operated by MRMIB or the California Department of Health Care Services immediately at birth depending on your income. You will receive information about eligibility for these programs and the process for registration of your infant from the State.
ALLIED HEALTH PROVIDERS. Health care professionals other than physicians (e.g., physical therapists, podiatrists, chiropractors).
ALLOWABLE COSTS. The portion of charges billed by providers which qualify as reimbursable. Almost always less than the actual billed charges.
ALOS (See “Average Length of Stay”). AMBULATORY CARE Same as outpatient services (e.g., a physician office visit). These are services which do not require institutionalization of a patient.
AMR Abbreviation for “American Medical Response”, the company that provides local emergency and non-emergency transportation services for CenCal Health members.
ANCILLARY SERVICES Used to describe additional services performed in conjunction with a physician’s care, such as lab and x-ray testing.
ANSI Abbreviation for “American National Standards Institute”. This organization establishes standards for data processing.
APS Abbreviation for “Adult Protective Services”, a unit within the County Department of Social Services that is charged with ensuring the safety of those who are no longer competent to handle their own affairs.
AUTHORITY Refers to CenCal Health, formerly known as SBRHA.
AUTHORIZATION The approval of medical care qualifying for reimbursement. Can be prior, concurrent, or retrospective.
AVERAGE LENGTH OF STAY (ALOS) Refers to the average number of days of hospitalization. Is calculated by dividing the total days by the total admissions for a specified period of time.
AWARE Abbreviation for the “Alliance Working for Antibiotic Resistance Education”. A statewide program which aims to increase awareness of the growing problems with resistance to antibiotics due to overuse and abuse. CenCal Health is a pilot site for this program.
AWP Abbreviation for “Average Wholesale Price”. One of the determinants of the price paid for a pharmaceutical product.
B
BAT (Baseline Assessment Tool) An instrument used by external auditors to assess the accuracy and quality of a health plan’s data reporting under the HEDIS® program.
BBA (Balanced Budget Act). The BBA was passed into law by the Congress in 1997; it is well known throughout the health industry for its severe reductions in payments for Medicare providers; hospitals and Medicare HMOs were particularly hard hit by the provisions of this Act.
BCEDP (Breast Cancer Early Detection Program). A special State Medi-Cal program which providers reimbursement for breast cancer screening and detection services.
BENEFICIARY A member covered by one of CenCal Health’s programs.
BIC (Beneficiary Identification Card). This is a permanent plastic card issued to Medi-Cal beneficiaries. It has an electronic strip, which contains information about the person. It does not guarantee eligibility.
BOARD CERTIFIED Used to describe a physician who has passed an examination given by a medical specialty board, and who has met all the requirements for certification as a specialist in that medical specialty.
BOARD ELIGIBLE Used to describe a physician who is eligible to take the specialty board examination because they have met all the other requirements to be certified (e.g., completed necessary training and practice requirements).
C
CAB (Community Advisory Board). One of the official advisory boards to CenCal Health, whose membership is made up of beneficiaries and beneficiary representatives.
CAHHS (California Association of Hospitals and Health Systems). Formerly the California Hospital Association. The statewide hospital trade group in California.
CAHPS (Consumer Assessment and Health Plan Survey). A member survey designed for measuring the strengths and weaknesses of health plans; it is a tool that has been standardized by the state and federal governments and can be used by any health plan.
CAHP (California Association of Health Plans). State HMO trade group; CenCal Health is a member.
CALOPTIMA One of the six COHS plans; service area is Orange County.
CALWORKS See “AFDC”.
CAP (Corrective Action Plan). This is the response outlining the actions that CenCal Health or a provider will take, and when, required in response to CenCal Health or regulatory agency audit findings.
CAPITATION Means a payment in the form of a per capita (or per person) amount. CenCal Health is paid in this way by DHS for Medi-Cal (SBHI/SLOHI) patients, and CenCal Health pays its primary care physicians using the capitation methodology.
CARADIGM The CenCal Health-developed Health Information System, which handles all eligibility, claims processing, and reporting functions.
CARE DATA EXCHANGE (CDE) A pilot project funded by the California Healthcare Foundation in which several entities, each with their own set of partners, are developing automated systems that will permit electronic sharing of medical information. CenCal Health is one of the participating partners. The CDE is organized as as a non-profit benefit corporation, with its own Board of Directors.
CASE MANAGEMENT Describes the responsibility of the PCP to provide and/or arrange for the provision of coordinated, continuous medical services for the patients under his/her care.
CASE MANAGER A term for the health professional (usually the PCP) who is responsible for the case management of a patient. The CenCal Health Utilization Management Coordinators also may assist in case management of difficult cases.
CBO (Community-Based Organization) Refers to those non-profit agencies in the community which provide needed human services to the local population, usually at reduced or no cost.
CCAH See “Central Coast Alliance for Health”.
CCN (Claims Control Number) A unique number assigned by CenCal Health to every claim received from providers.
CCR (California Code of Regulations) The administrative regulations for State programs; Medi-Cal regulations are found at Title 22 of the CCR.
CCS (California Children Services) A State program, under the auspices of DHS, for physically challenged or severely disabled children, up to the age of 21. CCS services are included under the CenCal Health Medi-Cal contract with DHS.
CCU (Coronary Care Unit). Acute inpatient bed unit in a hospital, used for coronary care patients in need of intensive care and monitoring.
CDE See “Care Data Exchange”.
CENTRAL COAST ALLIANCE FOR HEALTH (CCAH). One of the six COHS plans, covering Santa Cruz, Monterey, and Merced counties.
CERTS (Claims and Eligibility Real Time System). Software distributed by EDS, which allows the user to electronically submit pharmacy claims, verify eligibility, clear SOC liability, and make Medi-Reservations using a Personal Computer.
CFR (Consideration for Reselection). These are requests made by members who wish to change PCPs for reasons other than those which are automatically granted.
CHAMPUS Refers to the federal government’s health care program for those serving in or retired from military service (now referred to as “TRICARE” or “TRICARE/CHAMPUS”).
CHCF Refers to the “California Healthcare Foundation”, a charitable foundation endowed with moneys from the conversion of Blue Cross of California from a non-profit to a for-profit entity.
CHDP (Child Health and Disability Prevention Program). This is California’s version of the Federal EPSDT program. It provides for the payment of regular screening checkups and immunizations for children. CenCal Health administers payment of CHDP services for dates of service on and after July 1, 2016 for all SBHI/SLO CenCal Health members.
CHS (Cottage Health System). A multiple hospital system comprised of Santa Barbara Cottage Hospital, Goleta Valley Cottage Hospital, and Santa Ynez Cottage Hospital.
CHW Stands for the Catholic Healthcare West, a consortium of Catholic owned and/or managed hospitals.
CIC Refers to Clinical Improvement Committee. This advisory group is made up of medical professionals appointed by the CenCal Health Board of Directors, and is responsible for implementing the QAIP.
CIF (Claims Inquiry Form) A form used by providers to request adjustments on paid or denied claims, or to trace a claim on which they have not yet received reimbursement.
CIN (Client Index Number). A unique nine-character number assigned to every person who qualifies for Medi-Cal. The CIN appears on the front of the BIC when the recipient has no Social Security number.
CLASS I Refers to all SBHI patients whose care is managed by a contracting PCP. Those not in Class I are placed in “Special Class”.
CLIA (Clinical Laboratories Improvement Act). A federal law which requires all providers (including physicians) who perform certain laboratory tests, to meet specific standards and to be certified by HCFA, in order to receive payment for laboratory services from Medicaid and Medicare.
CMA The California Medical Association. The physician trade group in California.
CMAC (California Medical Assistance Commission). Established by State law in 1983, CMAC is responsible for negotiating Medi-Cal contracts with hospitals and certain other health systems in California. Commissioners are appointed by the Governor and the Speaker of the Assembly. All COHS plans except CenCal Health negotiate their Medi-Cal contracts with CMAC.
CME (Continuing Medical Education). Programs under which physicians, nurses, and other medical professionals receive ongoing education in their fields, as is required in order to maintain their license to practice.
CMS (The Center for Medicare and Medicaid Services). Formerly known as the Health Care Financing Administration or HCFA, this federal agency, under the authority of the U.S. Department of Health and Human Services, oversees the Medicare and Medicaid programs.
COB (Coordination of Benefits). Pertains to the handling of claims for patients who have more than one insurance coverage. Medi-Cal, by State and Federal law, must attempt to first collect from the other carrier when a patient has Medi-Cal and other coverage. CenCal Health maintains an aggressive program for making recoveries from other payors.
COBRA (Consolidated Omnibus Budget Reconciliation Act). Sometimes used to refer to the annual Federal budget law; sometimes also called OBRA.
CODE 1 Refers to the restriction placed on certain drugs, in which their use is restricted to only certain conditions or diagnoses.
COGS (Complaint or Grievance System). Refers to the protocol approved by the State which governs the handling of member and provider complaints and grievances by health plans such as CenCal Health.
COHS (County Organized Health System). This refers to the 6 health plans which have contracted with DHS to administer the Medi-Cal program for an entire county. CenCal Health, HPSM, CCAH, GCHP, CalOPTIMA, and PHC are the six COHS plans in California, covering the counties of Santa Barbara, San Luis Obispo, San Mateo, Orange, Solano, Napa, Yolo, Santa Cruz, Merced, Ventura, and Monterey.
CONCURRENT REVIEW An assessment of persons currently in an acute care hospital, SNF or ICF, conducted by CenCal Health utilization management staff, which is done to determine the medical necessity of the stay under Medi-Cal guidelines.
COPAYMENT An amount which a subscriber of a health insurance plan must pay for use of specific medical services covered by the plan.
CPSP (Comprehensive Perinatal Services Program). This is a State program, which is designed to ensure that pregnant women in the Medi-Cal program receive timely and adequate prenatal care (including nutritional counseling, psychosocial assessments, health education, etc.). The program is covered through SBHI in Santa Barbara County. The reimbursements for services are set by the State, and used by SBHI in paying its CPSP providers. Providers must be certified by the State to provide CPSP services.
CPT (Current Procedural Terminology). Descriptive terms and codes used for reporting on claim forms, medical services and procedures performed by physicians and certain other providers. Each service or procedure is identified with its own unique 5 digit code.
CREDENTIALING The process followed by CenCal Health in determining that the providers with whom it contracts are properly licensed and can provide quality care to its members.
CROSSOVER See “Medi-Medi”.
CURRENT RATIO A common measure of financial strength, it is the ratio of current assets to current liabilities. The measure indicates a company’s ability to meet its current obligations. The CenCal Health contract with DHS requires a minimum current ratio of 1:1.
CRVS (California Relative Value Scale). A listing of procedure codes and their values; used for billing and assigning reimbursement values to services rendered by physicians.
D
DEPARTMENT OF HEALTH SERVICES (DHS) The Department in California State government responsible for health program administration. These responsibilities include the State FFS Medi-Cal program, and the Medi-Cal Managed Care programs. A department of the California Health and Human Services Agency.
DEPARTMENT OF MANAGED HEALTH CARE (DMHC) The Department in California State government responsible for the licensing and monitoring of health care services plans.
DHHS (Department of Health and Human Services). The Federal Department responsible for administration of all Federal health programs. The DHSS Center for Medicare and Medicaid Services (CMS) oversees the Medicare and Medicaid programs.
DHS See “Department of Health Services”.
DISCHARGE PLANNING The activities carried out by hospital and nursing home staffs, in evaluating a patient’s needs for appropriate care after discharge from the inpatient setting, and coordinating that care.
DISPROPORTIONATE SHARE HOSPITAL (DSH) Hospitals which serve what is defined by federal and state laws as a “disproportionate” share of Medicaid, Medicare and non-insured (no pay) patients, are eligible to receive additional payments from various sources, in an effort to compensate the hospitals for this service.
DMHC See “Department of Managed Health Care”.
DME (Durable Medical Equipment). Equipment which can tolerate repeated use, and is primarily needed because of a medical condition. Some such equipment requires prior authorization by SBRHA in order to be reimbursable. Examples of common DME are hospital beds, wheelchairs, and oxygen equipment.
DOORWAY TO HEALTH The dba name for SBRHA’s charitable foundation, which accepts donations that are designated to activities consistent with the Authority’s mission.
D.P. (Distinct Part). Usually refers to the “distinct part” beds of an acute hospital, which are used for patients whose medical condition does not require acute level care, but does require that the patient be in close proximity to the services of an acute hospital. The distinct part beds can be inside the hospital, or in a separate facility. In Santa Barbara County, there are two DP facilities: the Lompoc Convalescent Care Center and the Marian Extended Care Center.
DRGs (Diagnosis-Related Groups). The method used by the Federal Medicare program to reimburse hospitals for inpatient services. The method classifies services according to diagnoses, and there is a set reimbursement for each DRG, regardless of the patient’s length of stay in the hospital.
DRUG FORMULARY A listing of prescription drugs which are approved for coverage, and which can be dispensed without prior authorization. CenCal Health uses the State Medi-Cal Drug Formulary as a base, and over the years has modified it substantially. Any medications not on the CenCal Health Formulary require prior authorization to be reimbursable.
DSH See “Disproportionate Share Hospital”.
DSS (Department of Social Services). The Santa Barbara County Department of Social Services, which is responsible for administering the welfare assistance programs, and determining eligibility for the Medi-Cal program for residents in the County.
DX Abbreviation for “diagnosis”.
E
ED Stands for Emergency Department; see “ER”.
EDS (Electronic Data Services) The current contractor to DHS, which processes Medi-Cal FFS claims. This contractor is also referred to as the FI, or Fiscal Intermediary.
ELECTRONIC MEDICAL RECORD (EMR) Refers to a system in which a medical record is maintained in an electronic format.
EMERGENCY Under State Medi-Cal regulations, defined as a situation in which, if immediate medical care is not rendered, loss of life or permanent disability would result.
EMR (See “Electronic Medical Record”).
ENCOUNTER FORM The form used by a primary care provider to report the rendition of any capitated services to case managed patients.
EOB (Explanation of Benefits). The form sent by CenCal Health to a provider who has billed for services, which may be accompanied by a payment (check), and explains the disposition or status of any claims outstanding (i.e., how much was paid, if claim was denied and why, or claim is pended and why). In the Medicare program, it is referred to as an EOMB (Explanation of Medicare Benefits). Sometimes also referred to as a RA (Remittance Advice).
EOC (Evidence of Coverage). A document required by State regulations which discloses to prospective and current members all details of their health care coverage through a health plan.
EPO (Established Patient Only). Designation for a contracted PCP who is accepting only established patients (i.e., no new patients).
EPSDT (Early Periodic Screening, Detection and Treatment). The federal program, called the CHDP program in California (see “CHDP”).
EQRO (External Quality Review Organization). An independent review organization that contracts with the California Department of Health Services to perform quality of care audits of contracting Medi-Cal managed care plans.
ER (Emergency Room). The hospital department which is equipped and staffed to treat emergency conditions, and is open 24 hours a day. All acute care hospitals in Santa Barbara County, except RISB, have licensed ERs.
EVIDENCE OF COVERAGE See “EOC”.
EW (Eligibility Worker) An employee of DSS who is responsible for determining eligibility for public assistance programs, such as CalWorks.
F
FAME (Fiscal Intermediary Access to MEDS). Eligibility information supplied by DHS to the FI in order to process FFS claims. CenCal Health obtains the FAME information via a daily electronic download from DHS, in order to ensure that its eligibility database is up to date.
FEDERAL POVERTY LEVEL (FPL) This is the income level set by the Federal Government and revised each year, below which a family is considered in poverty. It is widely used for eligibility in many federal and state assistance programs, including welfare cash grants and qualification for Medi-Cal and other health programs for low-income persons. Sometimes also referred to as “Federal Income Guidelines”.
FFS (Fee-for-Service). Refers to the method of payment to providers, in which the provider is paid a set fee for each service provided. The traditional method of payment to providers of medical services.
FI (Fiscal Intermediary). The contractor who is responsible for processing and paying claims for health programs. For the California Medi-Cal program, EDS is the contracted F.I. (see “EDS”).
FIRST 5 Also known as the Children and Families Commission, this body makes the decisions on how local tobacco tax moneys are to be expended, restricted to services for children age 5 and under. There is also a state FIRST 5 Commission, which allocates the California share of these tax moneys.
FISCAL YEAR (FY) The 12 month period used by an organization for recording and reporting of financial information. The Authority’s fiscal year runs from July 1 to June 30.
FPL (see “Federal Poverty Level”).
FQHC (Federally Qualified Health Center). Pursuant to Federal law, certain medical providers can qualify as a FQHC provider. Once qualified, the provider is entitled to receive payment from Medicaid at 100 % of its reasonable costs, as determined by DHS. The program is intended to provide financial assistance to those “safety net” providers who see a disproportionate share of Medicaid patients, so that they can remain in business to provide these services. In Santa Barbara County, there are currently five providers who have received FQHC designation — Santa Ynez Indian Clinic, Guadalupe Community Clinic, Community Health Centers of the Central Coast, American Indian & Health Services, and SBCPHD.
G
GATEKEEPER The name often used to describe the primary care physician in a managed care delivery system, since the PCP controls the access to most medical services needed by the patient.
GENERIC DRUG A chemical equivalent of a name-brand drug, which is manufactured by another company, since the original patent on the name brand has expired. The generic version is usually less expensive, and therefore many managed care programs either encourage or require the use of generics, when they are available, and when the prescribing physician permits substitution.
GEOGRAPHIC MANAGED CARE (GMC) One of the three Medi-Cal managed care programs administered by DHS, in which several health plans contract directly with DHS in a certain area, and compete for Medi-Cal patients. The only currently operating GMC plans are in Sacramento and San Diego counties.
GENETICALLY HANDICAPPED PERSON’S PROGRAM (GHPP) A special Medi-Cal program for persons who qualify under California regulatory requirements.
GMC (see “Geographic Managed Care”).
GVCH Goleta Valley Cottage Hospital.
H
H&P Refers to the “History and Physical” information contained in a patient’s medical record.
HCBS (Home and Community Based Services). A waiver program under Medi-Cal, which allows Medi-Cal clients to receive medical services in their homes, thus avoiding institutionalization.
HCPCS (HCFA Common Procedural Coding System). A listing of services, procedures and supplies, and their associated codes, used by physicians and other providers in billing for services. HCPCS includes CPT codes, and national and local alpha-numeric codes. The national codes are developed by HCFA to supplement the CPT codes. They include physician services not included in CPT, as well as non-physician services such as ambulance, physical therapy and DME. The local codes are developed by local Medicare carriers in order to supplement the national codes. HCPCS codes are 5 digit codes with the first digit being a letter, followed by four numbers. HCPCS codes beginning with A through V are national, and those beginning with W through Z are local.
HEALTHY FAMILIES PROGRAM (HFP) The California version of the federal State Children’s Health Insurance Program (S-CHIP). It is a program of health care for children, financed by Federal and State moneys ($2 for $1), and subscriber contributions. The children are from families who do not qualify for no cost Medi-Cal, with incomes up to 250% of the Federal poverty level. The services are delivered by health plans contracting with MRMIB, the administrator of the program in California. CenCal Health is one of four contracting plans in Santa Barbara County, and is also the designated “Community Provider Plan”, which means that it is recognized as the plan with the highest number of contracts with traditional safety-net providers.
HEALTHY KIDS A program now in existence in several California counties, which provides health coverage for children under the age of 19 who do not qualify for Medi-Cal or Healthy Families. These programs are generally funded through tobacco tax and settlement moneys, foundation and individual donations, and subscriber contributions. CenCal Health participated with a local Coalition and launched such a program in Santa Barbara County in 2005.
HEDIS (Health Effectiveness Data and Information Set). A standardized set of quality measures that are being increasingly used by health plans and regulators to measure the weaknesses and strengths of individual plans.
HFP or HF (see “Healthy Families Program”).
HIO (Health Insuring Organization). A term used by CMS to describe entities such as CenCal Health, which contract on a risk basis for publicly-funded health care programs, and have the responsibility of arranging for the provision of care to those covered by the funding (e.g., Medi-Cal). HIOs cannot provide care directly.
HIPAA (Health Insurance Portability and Accountability Act). This Act established the requirements that must be met by all health plans and providers viz. regarding standards governing electronic transactions and confidentiality of medical record information.
HIPC (Health Insurance Program of California). A program administered by Pacific Health Advantage under contract to MRMIB, which offers health insurance to small employers at rates normally available only to larger employers. Now called “PacAdvantage”.
HIPP (Health Insurance Premium Payment). A program in which CenCal Health pays the private health insurance premiums for a SBHI/SLOHI member with a high cost condition (most often AIDS), which is almost always more cost-effective than allowing the person’s coverage to lapse, forcing Medi-Cal to pick up all costs of care. All applications for the HIPP program are carefully reviewed by Cencal Health staff, and applicants are qualified only if they meet the standards established by the State-run program.
HIRF (Health Initiative Referral Form). The internal form used by the CenCal Health’s Health Services Department to document authorization of a procedure (e.g., when a PCP refuses to provide authorization for a service, and the CenCal Health Medical Director provides the authorization because medical necessity has been confirmed).
HMO (Health Maintenance Organization). An entity that provides or arranges for the provision of coverage of comprehensive medical services for a fixed, prepaid premium. The term was first officially used when the Federal HMO Act was passed in the early 1970’s. More than 40 million people are now enrolled in HMOs nationwide. HMOs use a managed care approach to delivering services. There are three basic types of HMOs — staff model (services provided by facilities owned by the HMO, with physicians employed by the HMO), group model (services provided under a contract with a medical group or groups, such as Kaiser Permanente Medical Group), and Independent Practice Association (or IPA, in which the HMO contracts with an association representing multiple providers in private practice, which in turn contracts with the individual providers, who see patients with many different payor sources.
HOME HEALTH SERVICES. Medically Necessary health services provided at the home of a Member as prescribed by a PCP or Participating Physician. Such Home Health Services shall include diagnostic and treatment services, which can reasonably be provided in the home, including services performed by a registered nurse, post-natal and newborn care and assessment, licensed nurse services, certified home health aide services, clinical social worker services, and qualified outpatient rehabilitation therapy services (such as physical, occupational, and speech therapy).
HOSPICE OR HOSPICE CARE. A specialized form of interdisciplinary health care that is designed to alleviate the physical, emotional, social and spiritual discomforts of a Member who has a medical prognosis of six months or less to live, and is provided in lieu of curative treatment for the terminal condition.
HPC (Health Plan Code). The code assigned by DHS to contracting Medi-Cal plans in California, and stored in FAME and MEDS.
HPSM (Health Plan of San Mateo). One of the other six COHS plans, covering San Mateo County.
HWDC (Health and Welfare Data Center). The data center run by the California Health and Human Services Agency. CenCal Health receives its Medi-Cal eligibility data from the HWDC.
HX Abbreviation for “history”; a medical record term, as in “history and physical”.
I
IBNR (Incurred But Not Reported). Refers to the costs associated with medical services rendered but not yet billed. Health plans like CenCal Health must be able to accurately estimate the IBNR liability on their financial statements.
ICD-9-CM (International Classification of Diseases — 9th Revision, Clinical Modification). The listing of standard diagnosis codes and their accompanying definitions.
ICD-10-CM (International Classification of Diseases — 10th Revision, Clinical Modification). The listing of standard diagnosis codes and their accompanying definitions. CMS requires the use of the ICD-10-CM code set for dates of service on and after October 1, 2015.
ICF (Intermediate Care Facility). A facility providing a level of care to individuals who do not require the level of care provided in a SNF, but do require care above that provided in a Board and Care facility (Board and Care facility services are not covered by the Medi-Cal program). ICF facilities are usually for the developmentally disabled; hence, the common acronym ICF-DD-H, a residential care facility which seeks to care for and habilitate developmentally disabled clients.
ICU (Intensive Care Unit) The specialized department in an acute care hospital which provides treatment for very ill/severely injured patients.
IHSS (In-Home Supportive Services). Services provided with State funding to homebound persons in order to assist with ADLs. IHSS is not a Medi-Cal benefit. IHSS workers (also known as “providers”) are employed by a Public Authority established and managed by the County DSS. CenCal Health has a contract with the Public Authority to provide a health insurance plan for qualifying IHSS workers; this product is called “IHSS Healthcare”.
ILRC (Independent Living Resource Center) A local non-profit organization which provides referral and support services for people with disabilities.
INPATIENT Means that a patient is being treated in an institutional health facility (usually refers to in-hospital status).
IPA (Independent Practice Association). See “HMO”.
IQIP (Internal Quality Improvement Project). A project proposed by the Authority and approved by DHS that fulfills established guidelines for interventions with a member population that can improve health status. These projects can be of either a clinical and non-clinical nature.
K
KNOX-KEENE HEALTH CARE SERVICE ACT Passed by the California Legislature in 1976, the Act establishes stringent regulations for the monitoring of organized health plans operating in the State. The implementation of these regulations rests with the Department of Managed Health Care (DMHC). The regulations require that health plans apply and receive a Knox-Keene license in order to operate in the State. The CenCal Health enabling legislation exempts its Medi-Cal program from Knox-Keene licensure requirements, although the contract with DHS incorporates many of its specific quality assurance and financial requirements. A license is required to contract with HFP, and CenCal Health was granted its license in June 2000. CenCal Health also has a license for its AIM and IHSS programs.
L
LAIF Refers to the “Local Agency Investment Fund”, a Fund which is composed of investment moneys from local government agencies that are pooled and managed by the State. There are no required minimum investment periods, and the interest rate available changes regularly. CenCal Health invests some of its idle funds in the LAIF.
LAN Refers to a “Local Area Network”, in which a specific group of PCs are networked to communicate with each other.
LAO (Legislative Analyst’s Office). This Office provides independent advice to the California Legislature
LCCC Lompoc Convalescent Care Center. A freestanding, distinct part SNF, owned and operated by LHD.
LHD Lompoc Healthcare District.
LI (See “Local Initiative”).
LIMITED SERVICES These services do not require PCP authorization, but are limited to a total of two per month under the Medi-Cal program. Special authorization is needed from SBRHA to exceed this limit. The services include acupuncture and chiropractic.
LOCAL INITIATIVE (LI) One of plans that operates under one of the three models for Medi-Cal managed care in California. Under the State’s “two-plan model” of managed care, this is the plan administered by a public agency, and competing for patients with the “mainstream” or private plan in a county.
LONG TERM CARE (LTC) Refers to the care for patients in long term care facilities (most commonly SNFs), who are in need of nursing care and assistance with ADLs.
LTC (See Long Term Care).
M
MAIC or MAC (Maximum Allowable Ingredient Cost) Refers to a pricing methodology for generic pharmaceuticals.
MANAGED CARE Refers to a system of health care delivery which organizes providers (generally around a primary care model), influences the utilization and cost of services, and has mechanisms to monitor and assure good quality of care. Managed care systems integrate clinical and administrative services in a cost-effective manner which assures the availability of care, in the most appropriate setting.
MANAGED RISK MEDICAL INSURANCE BOARD (MRMIB) A State agency, which is responsible for administering the AIM program, the Health Insurance Plan of California (“HIPC”, a program of health insurance for small employers), the Risk Pool plan for those with high cost conditions who cannot obtain private health insurance (MRMIP), and the Healthy Families program.
MCO Refers to “Managed Care Organization”.
MECC (Marian Extended Care Center). A freestanding but distinct part SNF, owned and operated by MMC.
MEDICAID The federal program, begun in 1965, which was intended to provide medical benefits to low income patients. Each State administers its own program, so there is no consistency from state to state. The costs are shared between the federal and state governments (in California, the program is called “Medi-Cal”).
MEDI-CAL The name for the Medicaid program in California.
MEDICALLY NECESSARY A service or treatment which is appropriate for a patient’s diagnosis, and which if not rendered, would adversely affect the patient’s condition. The Medi-Cal program covers only medically necessary services.
MN or MEDICALLY NEEDY ONLY (MNO) Aid category for persons eligible for Medi-Cal only, with no cash grant.
MEDICARE The federally-administered program, begun in 1965, which covers basic medical, hospital and (limited) pharmaceutical services (but not extended long term institutional care) for the elderly and disabled. Part A covers inpatient costs, and Part B covers outpatient costs.
MEDICARE ADVANTAGE (See Medicare Advantage).
MEDICARE+CHOICE (M+C) The federal program in which health plans enter into a risk contract with HCFA to provide a full range of Medicare services to enrolled Medicare beneficiaries, for a monthly capitation payment. The M+C plans generally offer additional benefits as an incentive for people for join. Under the new “Medicare Modernization Act”, these plans are now known as “Medicare Advantage”.
MEDI-MEDI Refers to persons eligible for both Medicare and Medi-Cal programs; also referred to as “crossover” patients or “dual eligibles”. Medicare pays first.
MEDI-RESERVATION Refers to the method of limiting the Medi-Services (or “Limited Services”) allowed under the Medi-Cal program, whereby a member is entitled only to two services per month; these services include acupuncture and chiropractic care.
MEDS (Medi-Cal Eligibility Data System). The California automated system which is used to record all eligibility information for Medi-Cal beneficiaries. MEDS information for those eligible in Santa Barbara and San Luis Obispo Counties is electronically transmitted to CenCal Health each day.
MEDSID A unique Medi-Cal member identification number. It is usually the Client Index Number. CenCal Health uses the MEDSID as a key to claims payment, authorizations and eligibility verification.
MEMBER A person covered under one of CenCal Health’s programs.
MEMBER SERVICES REPRESENTATIVE (MSR) The employees of CenCal Health who are responsible for all direct client and member contact; responsibilities include problem solving and PCP selection.
MENTAL HEALTH ASSESSMENT TEAM (MHAT) The MHAT program ensures that emergency paramedics (with mental health assessment training) are called to situations when there is a psychiatric emergency, assess the patient medically and mentally, and deliver the patient to the most appropriate care setting (e.g., an outpatient clinic, a hospital emergency room, or the County’s Psychiatric Health Facility). The Authority contributes money toward this program. Under these arrangements, CenCal Health saves money because patients are not routinely taken to the emergency room, and hence CenCal Health avoids both those costs and the ambulance costs for such services — and patients are provided care that is most appropriate to their condition. The contract has proven to be cost-effective, as well as a service to our members by keeping them out of the law enforcement system, hospital emergency rooms, and the County’s Psychiatric Health Facility whenever possible.
MHAT See “Mental Health Assessment Team”.
MIA or MI (Medically Indigent Adult) Patients who qualify for assistance with the cost of their medical care, through separate County programs, but do qualify for Medi-Cal. MIAs were part of the Medi-Cal program until 1983. Funding for the program comes from the State; the program has been traditionally underfunded, so that many counties have the State administer the program in their jurisdictions. The MIA program is administered by SBCPHD in Santa Barbara County, and is called the MIASP.
MIASP (Medically Indigent Adult Services Program). The MIA program in Santa Barbara County. See “MIA”.
MISC (Multi Integrated System of Care). A grant-funded pilot program, which involves the coordination of mental health care for those who qualify, among several Santa Barbara County departments.
MMC Marian Medical Center, located in Santa Maria. A CHW hospital.
MMCD (Medi-Cal Managed Care Division). The section of DHS that is responsible for overseeing the operations of the contracting Medi-Cal managed care health plans in California.
MORBIDITY The incidence and severity of sicknesses and accidents in a defined class of persons.
MORTALITY The death rate at each age as determined from prior experience.
MOU Abbreviation for “Memorandum of Understanding”. Generally used to memorialize an agreement between two parties when a lengthy detailed contract is not necessary.
MRF (Medication Request Form) For medications that are not on the CenCal Health Drug Formulary, prescribers must submit a MRF to MedImpact (see PBM). These requests are reviewed for medical necessity and appropriateness.
MRI (Magnetic Resonance Imaging). Sophisticated system of imaging bodily systems without the use of traditional X-rays.
MRMIB (see “Managed Risk Medical Insurance Board”).
MSR (see “Member Services Representative”).
MSSP (Multi-Purpose Senior Services Program). An SBCPHD-administered program for frail elderly adults, intended to provide services which help keep the patient in their home.
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NCQA (National Committee on Quality Assurance). A private organization that was originally sponsored by national health plans, which now is independent and establishes health plan quality standards, and issues highly sought-after certifications for plans that meet those standards.
NDC (National Drug Code). Refers to the uniform codes assigned to all pharmaceuticals approved by the FDA. Also can be used to refer to National Data Corporation, which provides an electronic “switch” between health plans and pharmacies for filing drug claims.
NICU (Neonatal Intensive Care Unit). An intensive care unit for infants of low birth weights and life-threatening medical conditions. SBCH maintains the only NICU in Santa Barbara County.
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OB Obstetrics. “OBs” refers to obstetricians.
OBRA Patients can qualify for Medi-Cal under this federal “amnesty alien” program, but most qualify only for limited services (pregnancy-related and/or emergency care only). “IRCA” stands for the Immigration Reform and Control Act.
OBRA (Omnibus Budget Reconciliation Act). The acronym sometimes used to refer to the annual federal budget.
OC (Other Coverage). When a Medi-Cal beneficiary has other health insurance coverage (such as Kaiser, Medicare, Blue Cross, etc.), the MEDS file will indicate the OC.
OFFICE VISIT Generally refers to physician services rendered in an outpatient setting.
OILs (Operating Instruction Letters). These are the confidential written instructions sent to the Medi-Cal fiscal intermediary (FI) from DHS, which direct the FI to make changes to the Medi-Cal reimbursement system.
ORACLE The name of a computer technology company which makes a product used by many businesses, called a relational data base management system (i.e., a product which instructs a computer on how to store, manage and retrieve data in an efficient manner). CenCal Health’s computer system uses ORACLE database products.
ORD (Office of Research and Demonstrations). A section of CMS which funds demonstration projects. CenCal Health received ORD funding during the planning stages of the SBHI pilot project in the early 1980s, by virtue of Medicaid waivers being granted to California to operate the program in Santa Barbara County.
OSHPD The Office of Statewide Health Planning and Development; a California State government agency.
OTC (Over the Counter). Refers to drugs and medical supplies which can be sold without a prescription.
OUTPATIENT Services which are rendered in an ambulatory (walk-in) setting, as opposed to an inpatient setting.
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PAB (See “Pharmacy Advisory Board”).
PAC (See “Provider Advisory Committee”).
PACADVANTAGE See “HIPC”.
PAID CLAIMS Refers to claims which have been paid by CenCal Health, per contractual allowances.
PALLIATIVE CARE. Patient- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and facilitating patient autonomy, access to information, and choice.
PALLIATIVE CARE PROGRAM. CenCal Health program for the Medi-Cal benefit for Palliative Care as required by Welfare and Institutions Code § 14132.75 for Medi-Cal managed care beneficiaries, without regard to age, who are not Medicare/Medi-Cal (dually-eligible) beneficiaries, which may include additional CenCal Health-only benefits, with specific deliverable and other requirements as outlined in the Provider’s agreement with CenCal Health or in the Provider Manual.
PAYABLE CLAIMS Refers to claims which have been processed and priced by CenCal Health, but for which payment has not yet been issued.
PBGH (Pacific Business Group on Health). A nationally known group of large companies in the Bay area which formed this organization to negotiate health plan coverage and rates for its member companies.
PBM (Pharmacy Benefit Manager) A company which provides to health plans, management of their pharmaceutical benefits. The PBM under contract to CenCal Health, which performs drug claim processing and prior authorization services, is MedImpact, effective August 1, 2004.
PCP (Primary Care Physician). A general internist, pediatrician, general practitioner, family practitioner, or obstetrician who contracts with CenCal Health for a capitated payment, and in return, agrees to provide primary medical services, and to coordinate most all other care needed, for a defined group of members.
PDR (Physician’s Desk Reference). This book has long been considered the authoritative source of information on pharmaceuticals, used primarily by physicians when prescribing for patients.
PEER REVIEW The process of evaluation of the quality of medical care rendered, using medical professionals, through review of medical records, grievance reports, and other methods.
PERS (Public Employee Retirement System). The retirement system for California State and local government employees; CenCal Health is a member.
PHARMACY ADVISORY BOARD (PAB) An advisory committee made up of contracting pharmacists, which advises CenCal Health on non-clinical pharmaceutical matters.
PHC (Partnership Health Plan of California). One of the other six COHS plans serving Medi-Cal patients; service area is Solano, Napa and Yolo counties.
PHP (Prepaid Health Plan) A now outmoded term which referred to a health plan which was licensed under the State Knox-Keene Act, and contracted with DHS on a per capita basis for Medi-Cal beneficiaries (in other words, an early precursor to a Medi-Cal managed care plan).
PICU (Pediatric Intensive Care Unit). A specialized care unit for children within an acute care hospital; only SBCH maintains a PICU in Santa Barbara County.
PIN (Personal Identification Number). A unique id number issued to each Medi-Cal provider, and is used to access confidential information about Medi-Cal beneficiaries.
PIP (Prospective Interim Payment). A fee-for-service payment methodology, used by the State Medi-Cal program, and by SBHI, to pay non-contracted hospitals. The payment is a percentage of billed charges, adjusted periodically by DHS, which represents the amount DHS determines is the allowable costs which can be reimbursed by Medi-Cal.
PMPM Refers to “per member per month”.
PNS The Provider Network System, which is a unique communication program developed by SBRHA that allows providers to electronically verify eligibility of members.
POS DEVICE (Point of Service Device). An electronic device, offered by EDS to Medi-Cal providers, through which a BIC can be swiped to obtain information on a patient’s eligibility, to reduce their SOC (if any), and/or to reserve a Medi-Service.
PPO (Preferred Provider Organization). A program in which contracts are negotiated with selected providers at discounted rates; members of a PPO who receive their services from the preferred providers usually pay little or no fees for doing so, but pay significantly more if they see a non-contracted provider. PPOs generally charge higher premiums than HMOs.
PP2 (See “Prenatal PLUS 2”).
PRENATAL PLUS TWO (PP2) The CenCal Health AIM program. CenCal Health is the sole contractor with MRMIB for management of the program in Santa Barbara and San Luis Obispo Counties.
PRIMARY CARE Refers to basic, general medical services rendered by a PCP.
PRIOR AUTHORIZATION The process of obtaining approval for coverage of a service prior to rendering of the service. Many Medi-Cal benefits are covered only with prior authorization. Failure to obtain usually will mean that Medi-Cal (or CenCal Health) will not pay the claim for that service.
PRO (Professional Review Organization). Organizations with which CMS contracts, to be responsible for evaluating the appropriateness of Medicare services and claims. The PRO for California is CMRI (California Medical Review, Inc.).
PROSPECTIVE AUTHORIZATION See “Prior Authorization”.
PROVIDER ADVISORY COMMITTEE (PAC) A committee which advises CenCal Health on matters pertaining to outpatient providers who are not physicians
PT Physical therapy.
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QA (Quality Assurance) Also referred to as Quality Improvement, or “QI”, since the purpose of a QA program is to monitor the quality of care delivered by contracted providers, detect problems, and inform the providers and work with them to improve the care so that it meets established community standards. The CenCal Health contract with DHS requires a formal QA program (see “QAIP”).
QAIP The Quality Assessment and Improvement Plan, a document developed and maintained by CenCal Health and approved by DHS, which sets forth the agency wide quality improvement activities. This document is reviewed and updated as needed by the CIC on an annual basis.
QI Abbreviation for “Quality Improvement”. See “QA”.
QM Abbreviation for “Quality Management”.
QMC (Quality Management Committee). A CenCal Health internal staff committee that works to ensure that policies and procedures for all operations of the agency are developed and carried out consistent with state, federal, and NCQA requirements
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RAF (Referral Authorization Form). The CenCal Health written authorization form initiated by PCPs to document their referrals to other services. Most services, including consultations by specialists, must have a RAF in order to be paid.
RBRVS (Resource Based Relative Value Scale). This classification system is used by Medicare for reimbursement of physician services. It purports to measure the training, skills, and effort required to provide a particular service. The RBRVS schedule and methodology was effective in January 1992, and was intended to correct the overcompensation of specialists (especially those performing surgeries) and undercompensation of generalists who perform more cognitive, primary care services.
REINSURANCE Reinsurance is also known as “excess risk” or “stop-loss” coverage, and it is designed to limit a plan’s exposure for high cost cases. Reinsurance can take two forms — individual, and aggregate. CenCal Health contracts with a private insurance carrier for all legitimate inpatient hospital claims per year per MediCal beneficiary.
RETROACTIVE AUTHORIZATION The process of obtaining coverage of a service or procedure after it has been rendered. Medi-Cal regulations are very specific as to what services, and under what conditions, retroactive authorization can be granted.
RETROSPECTIVE AUTHORIZATION See “Retroactive Authorization”.
RFP (Request for Proposals). A document which requests competitive proposals and costs bids for one or more specific services.
RISB Rehabilitation Institute of Santa Barbara.
ROBERT WOOD JOHNSON FOUNDATION (RWJF) A charitable foundation which funds many health care projects.
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SANSUM CLINIC A large multi-specialty group practice, with clinics in most areas of the County. Sansum Clinic contracts with SBRHA to see SBHI members.
SANTA BARBARA NEIGHBORHOOD CLINICS (SBNC) The group of community clinics in the Santa Barbara area that are under a single management structure. The three clinics are Westside, Carrillo, and Isla Vista.
SBCH Santa Barbara Cottage Hospital.
SBCPHD Santa Barbara County Public Health Department (formally “Health Care Services”).
SBHI The Santa Barbara Health Initiative; refers to the SBRHA Medi-Cal program.
SBNC See “Santa Barbara Neigborhood Clinics”.
SBRHA The Santa Barbara Regional Health Authority.
SED Severely Emotionally Disturbed Children. The County’s Department of Alcohol, Drug and Mental Health Services is responsible for the treatment of such children.
SERVICE AREA Refers to the geographical area in which a health plan is licensed to operate.
SHR (Special Handling Request). A request to pay all or part of a claim that would otherwise not be paid; it is reviewed and approved through an administrative process.
SMART The program developed by SBRHA in which diabetic members are closely case managed by a PCP, and are offered many support services through the health plan. The program also pays monetary incentives to participating physicians as recognition of meeting established benchmarks of diabetic care.
SNF (Skilled Nursing Facility). A freestanding or distinct unit of a hospital, which provides 24 per hour skilled nursing care to its residents, who are certified for that level of care.
SOC (Share of Cost). The out-of-pocket amount which some persons must pay each month toward the cost of their medical expenses, before they become eligible for Medi-Cal coverage for that month.
SPECIAL CLASS Refers to all SBHI beneficiaries who do not have a PCP. It includes AIDs patients, LTC residents, and those whose eligibility is determined retroactively. The SBHI identification cards list these member’s PCP as SBHI.
SPECIALIST PHYSICIAN A physician who has specialized in a specific area of medicine, by virtue of advanced education and training.
SSA The Federal Social Security Administration.
SSI (Supplemental Security Income). Federal grant assistance program for aged, blind and disabled persons. Those receiving SSI automatically qualify for Medi-Cal.
SSL (Secure Socket Layer). Technology to ensure secure connections and transactions over the Internet.
SSN Social Security Number.
SWIPE CARD READER Also referred to as a credit card reader of swipe card device. This device connects to a personal computer, allowing the user to pass the BIC through and obtaining Medi-Cal information about the patient. When using this device in conjunction with SBHI’s PNS software, no information needs to be keyed in separately.
SYCH Santa Ynez Cottage Hospital.
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TAR (Treatment Authorization Request). Refers to the document used by providers to request authorization for coverage of Medi-Cal services. The TAR is submitted to SBRHA, and is reviewed by the Health Services Department. TARs are either approved, denied, or deferred for additional information/justification of medical necessity.
TCRC (Tri-Counties Regional Center). The regional center covering the Santa Barbara County area, which receives State funding to provide case management and support services for the developmentally disabled.
TNE (Tangible Net Equity). Under the Knox-Keene Act, and included in the Authority’s contract with DHS, are minimum requirements for TNE. This measure is a guideline for a plan’s ability to meet its obligations, and the maintenance of a prudent reserve.
TPA (Third Party Administrator). In health care, generally an entity that performs claims processing and other administrative services under contract to a health plan or employer with self-insured plans.
TPN Total parenteral nutrition.
TRICARE See “CHAMPUS”.
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UM (Utilization Management). The formal review of utilization of services, and the appropriateness of the services, conducted by the SBRHA Health Services Department staff professionals on prospective, concurrent, and retrospective bases.
UPL Stands for “Upper Payment Limit”. This is the level of payment PMPM under the Medi-Cal FFS program; the capitation payments to Medi-Cal managed care plans by DHS cannot exceed this threshold.
UR (Utilization Review). See “UM”.
UTILIZATION The measurement of the frequency of the use of services by members. Usually expressed as the number of services used per year per 1,000 members (e.g., the SBHI hospitalization rate is approximately 600 days per 1,000 members per year).
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VBAC (Vaginal Birth After Cesarean). Refers to the practice of having a woman deliver vaginally subsequent to one or more deliveries by c-section.
VIRF (Verbal Authorization Referral Form). The form used by the SBRHA Health Services Department staff to document authorization of a service or procedure granted over the telephone. The provider must always follow up such verbal authorization with a written TAR.
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WAIVER Refers to the CMS procedure of granting an exception to Federal Medicaid rules to permit the operation of SBHI; this is necessary because the SBHI program differs in substantive ways from the State FFS Medi-Cal program.
WAN Refers to a “Wide Area Network”, in which several diverse computer systems are linked in a network so as to be able to communicate with each other. The Authority is linked to the Santa Barbara County WAN.
WIC (Women, Infants, and Children’s Program). A program, administered by the County, which provides nutritional counseling and food coupons (for milk, infant formula and nutritional foods) for no or low income pregnant and lactating women, and for infants and children up to the age of 18 months.