QUEST Integration – Glossary

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

Activities of Daily Living (ADL):

Activities a person performs on a daily basis, for self care, such as feeding, grooming, bathing, ambulating, dressing and toileting

Adult day care:

A licensed facility that is maintained and operated by an individual, organization, or agency for the purpose of providing regular care which includes supportive care to four or more disabled adults

Adult day health center:

A licensed facility that provides organized day programs of therapeutic, social, and health services to adults with physical or mental impairments, or both, which require nursing oversight or care, for the purpose of restoring or maintaining, to the fullest extent possible, their capacity for remaining in the community

Allowance:

The amount paid by QUEST Integration for a healthcare or service.

Assisted living facility:

A licensed facility that consists of a building complex offering dwelling units to individuals and services to allow residents to maintain an independent assisted living lifestyle.The facility is designed to maximize the independence and self-esteem of limited-mobility persons who feel that they are no longer able to live on their own.

Authorized representative:

A person who can make care-related decisions for a member who is not able to make such decisions alone. A representative may, in the following order of priority, be a person who is:

• A court-appointed guardian of the person
• A spouse or other family member (parent) as designated by the member or the State according to HRS 327E-5; or
• Any other person who is not court-appointed, not a spouse or other family member who is designated as the member's healthcare representative according to HRS 327 E-5.

Benefit year:

The calendar year from January 1 to December 31.

Capitation:

An amount prepaid monthly to a health center or group per member for eligible services the health center or group is contracted to provide.

Charge:

The amount charged by the provider for services rendered.

Children:

All members under the age of twenty-one (21) years of age for coverage benefit purposes only.

Claim:

A bill for services, a line item of services, or all services for one member within a bill.

Clean claim:

A claim that can be processed without obtaining additional information from the provider of the service or its designated representative. It includes a claim with errors originating in a State’s claims system. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity.

CMS:

Centers for Medicare & Medicaid Services, the organization within the FederalS. Department of Health and Human Services that administers the Medicare and Medicaid programs.

CMS 1500:

Nationally accepted claim form for non-institutional billing, excluding dental and pharmacy claims.

Community Care Foster Family Home (CCFFH):

A certified home that provides 24-hour living accommodations, including personal care and homemaker services

Community Care Management Agency (CCMA):

An agency that engages in locating, coordinating and monitoring comprehensive services to residents in community care foster family homes or members in E-ARCHs and assisted living facilities.

Copayment:

A specific amount owed by a member at the time services are rendered.

CPT-4:

Common Procedural Terminology, a coding structure for medical procedures issued by the American Medical Association.

Cultural competency:

A set of interpersonal skills that allow individuals to increase their understanding, appreciation, acceptance and respect for cultural differences and similarities within, among and between groups and the sensitivity to know how these differences influence relationships with members.This requires a willingness and ability to draw on community-based values, traditions and customs, to devise strategies to better meet culturally diverse member needs, and to work with knowledgeable persons of and from the community in developing focused interactions, communications and other supports.

DHS:

Department of Human Services, the state Agency responsible for administering Hawaii QUEST Integration.

DSM IV:

Diagnostic and Statistical Manual of Mental Disorders, 4th Edition.

Days:

Calendar days

EMC:

Electronic media claim.

EPSDT:

Early and Periodic Screening, Diagnostic, and Treatment, a mandated program under Title XiX of the Social Security Act that provides services for children up to age of 21 years that emphasizes the importance of prevention through early screening for medical, dental and behavioral health conditions and timely diagnosis and treatment of conditions that are detected. It covers all services under Title XIX of the Social Security Act that are included in Section 1905 (a) of the Social Security Act, when medically needed, to correct or ameliorate defects and physical and mental illness and conditions discovered as a result of EPSDT screening.

Emergency Medical Condition:

A medical condition manifesting itself by a sudden onset of symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairments of bodily functions, or serious dysfunction of any bodily organ or part. An emergency medical condition shall not be defined based on lists of diagnoses or symptoms.

Emergency Services:

Any covered inpatient and outpatient services that are furnished by a provider that is qualified to furnish services and that are needed to evaluate or stabilize an emergency medical condition.

Expanded Adult Residential Care Home (E-ARCH):

A licensed facility that provides twenty-four (24) hour living accommodations, for a fee, to adults unrelated to the family, who require at least minimal assistance in the activities of daily living, personal care services, protection, and healthcare services, and who may need the professional health services provided in an intermediate care facility or skilled nursing facility. There are two types of expanded care ARCHs in accordance with Section 321-15.62, HRS:

• Type I – home allowing five (5) or fewer residents provided that up to six (6) residents may be allowed at the discretion of the department to live in a type I home, with no more than three (3) nursing facility level residents; and
• Type II – home allowing six (6) or more residents with no more than twenty percent (20%) of the home's licensed capacity as nursing facility level residents

Fee-for-service:

A method of charging whereby a physician or other healthcare provider bills and is paid for each encounter or service.

Fraud:

The intentional deception or misrepresentation made by an entity or a person with the knowledge that the deception could result in some unauthorized benefit to the entity, her/himself, or to some other person in a managed care setting.

HCPCS:

Centers for Medicare & Medicaid Services’ Common Procedure Coding System, created by CMS and required when reporting procedures and services provided to Medicare and Medicaid beneficiaries; includes HCPCS and CPT codes.

Home and Community Based Services (HCBS):

Long-term services and supports provided to individuals who meet nursing facility level of care to allow those individuals to remain in their home or community.

Homebound:

When due to an illness or injury, a patient is unable to leave home, or when doing so requires a considerable and taxing effort.

ICD-9-CM:

International Classification of Diseases, Ninth Edition – Clinical Modification, a classification system and coding structure of diseases.

Independent Activities of Daily Living (IADL):

Activities related to independent living, including preparing meals, running errands to pay bills or pick up medication, shopping for groceries or personal items, and performing light or heavy housework.

Inquiry:

A request by a provider for response to a particular concern or question, or to resolve a specific problem involving claims filing, benefits or payments.

Length of stay:

The number of days for which inpatient services are provided, including the day of admission and excluding the day of discharge.

Long-Term Services and Supports (LTSS):

A continuum of care and assistance ranging from in-home and community-based services for individuals 65 years or older and individuals with a disability(ies) who need help in maintaining their independence, to institutional care for those who require that level of support.

Medicare:

A federal program authorized by Title XVIII of the Social Security Act, as amended, which provides health insurance for persons aged 65 years and older and for other specified groups. Part A of Medicare covers hospitalization; Part B of the program covers outpatient services and requires a premium; Part C which is an alternative to Parts A and B and offers managed care options, and Part D of the program which covers prescription drugs and may require a premium.

Member:

An individual who has been designated by the Med-QUEST Division to receive medical services through the QUEST Integration program as defined in Section 30.300 and is currently enrolled in a QUEST Integration health plan.

Nursing facility:

A licensed facility that provides appropriate care to persons referred by a physician. Such persons are those who:

• Need 24 hour a day assistance with the normal activities of daily living;
• Need care provided by licensed nursing personnel and paramedical personnel on a regular, long-term basis; and
• May have a primary need for 24 hours of skilled nursing care on an extended basis and regular rehabilitation services.

Open enrollment period:

An annual time period established by DHS when existing members may transfer between health plans and change PCPs; also known as the Annual Plan Change Period.

Outpatient care:

Hospital services and supplies furnished in the hospital outpatient department or emergency room and billed by a hospital for the care of a patient who is not a registered bed patient.

Participating provider:

A provider who agrees in a written contract to accept HMSA's QUEST Integration reimbursement for a service as payment in full.

Payment determination requirement:

A medical service rendered to a QUEST Integration member that follows standard medical practice and is deemed essential and appropriate for the diagnosis or treatment of a particular illness or injury.

PCP:

Primary Care Provider. A provider who is licensed in the State of Hawaii and is (1) a physician, either an M.D. (Doctor of Medicine) or a D.O. (Doctor of Osteopathy), and must generally be a family practitioner, general practitioner, general internist, pediatrician, obstetrician/gynecologist (for women, especially pregnant women), or geriatrician; or (2) an advanced practice registered nurse with prescriptive authority; or (3) a licensed physician assistant.

Personal assistance:

Care provided when a member, member’s parent, guardian or legal representative employs and supervises a personal assistant who is certified by the health plan as able to provide the designated services whose decision is based on direct observation of the member and the personal assistant during the actual provision of care. Documentation of this certification will be maintained in the member’s individual plan of care.

Post-stabilization services:

Covered services related to an emergency medical condition that are provided after a member is stabilized in order to maintain the stabilized condition or to improve or resolve the member’s condition.

Precertification:

Authorization by HMSA issued before the rendering of the service that the service meets payment determination requirements and will be covered subject to patient eligibility. The term precertification is the same as prior authorization.

Quality care:

Care that is accessible and efficient, provided in the appropriate setting, according to professionally accepted standards and in a coordinated and continuous rather than episodic manner.

Referral:

Specialty care requested by a PCP for a patient.

Report to provider:

The statement mailed to providers detailing the claims paid or denied, including explanations for those denied. The term Report to Provider is the same as Remittance Advice.

SEBD (Support for Emotional and Behavioral Development):

Describes children from birth to age 18 who, as the result of a mental, behavioral or emotional disorder of a sufficient duration to meet the diagnostic criteria specified within DSM III-R, exhibit emotional, cognitive or behavioral functioning that interferes substantially with their family, school or community activities.

Service coordination:

The process which assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet a member’s healthcare needs using communication and all available resources to promote quality outcomes. Proper care coordination occurs across a continuum of care, addressing the ongoing individual needs of a member rather than being restricted to a single practice setting.

Service Coordinator:

An individual who coordinates, monitors and ensures that appropriate and timely care is provided to the member.A service coordinator may be a specific person selected by the member or assigned by the health plan.

Service date:

Date on which a healthcare service was rendered by a provider to a member.

Service Plan:

A written plan based on an assessment that includes, but is not limited to, the following:

• Goals, objectives or desired outcomes, and
• A list of all services required (Medicaid and non-Medicaid) the amount, the frequency and duration of each service, and the type of provider to furnish each service.

SMI:

Seriously mentally ill, describes adults who, as a result of a mental disorder, exhibit emotional, cognitive, or behavioral functioning which interferes substantially with their ability to remain in the community without supportive treatment or services of a long-term or indefinite duration. Mental disability is serious and persistent resulting in a long-term limitation in their functional capacities for primary activities of daily living. Conditions such as mental retardation or substance abuse may cause similar problems or limitations but are not to be included in this definition unless, in addition to one or more of those disorders, the person has a serious and persistent mental disorder.

Standard medical practice:

Most physicians in the nation regard the services as safe and effective. If a service is in its trial stages (e.g., “experimental” because it is used in research on animals or “investigative” because it is or has been performed on a limited number of people), the service is not considered standard medical practice for purposes of benefit payment.

Suspended claim:

A claim that requires further action or review before it is paid or denied.

TPL:

Third Party Liability, other health insurance benefits available to a member. It also may refer to a right to reimbursement of health benefits from a third party found liable for a member’s illness or injury.

UB-04:

Nationally designed claim form for institutional billings.

Urgent care:

The diagnosis and treatment of medical conditions which are serious or acute but pose no immediate threat to life and health but which require medical attention within 24 hours. Examples include but are not limited to sprains and strains, scrapes, ear aches, sore throat.

Revision History