I know that not all readers here are from the U.S., but those from other countries might find this interesting as well, even if it's just to see examples of how complex the American health care system is. Some friends and I are working on a project to help people increase the chances of their success at appealing denials of their health insurance coverage for procedures and medicines. In the course our research, we’ve come across many terms, abbreviations, and acronyms for which familiarity is helpful. Some of these are quite common, with easily recognized or understood meaning, while others are seen less frequently, but are no less important. Here is a list of some of these; more will be added as they arise during our work. Other terms and more detailed descriptions of some entries below can be found at https://www.healthcare.gov/glossary/.

CPT=Current Procedural Terminology — classification codes for medical procedures

HCPCS=Healthcare Common Procedure Coding System — a name for the system which uses CPT codes

ICD=International Classification of Diseases —disease classification codes; begun as the International List of Causes of Death in 1893 by Jacques Bertillon; includes a series of revisions starting with ICD-1 through ICD-11(present day version)

DOI=Department of Insurance (i.e. IDOI for Illinois Department of Insurance, LDOI for Louisiana Department of Insuramce, etc.)

OGB=Office of Group Benefits

HIPAA=Health Insurance Portability and Accountability Act — references to this acronym most often occur along with mentions of privacy and confidentiality of personal medical data

CNS=Clinical Nurse Specialist

PA=Physician’s Assistant

PCP=Primary Care Physician

MH=Mental health

SUD=Substance Use Disorder

CBC=Complete Blood Count

EHB=Essential Health Benefit

EBSA=Employee Benefits Security Administration

ERISA=Employee Retirement Income Security Act

NQTL=non-quantitative treatment limitations; examples can be found here: https://nqtls.com/nqtl-examples-non-quantitative-treatment-limitations/

HMO=Health Maintenance Organization — an insurance plan in which service is provided by and limited to a network of member providers

CDHP=Consumer Driven Health Plan — health insurance plan in which consumers use pretax money to help pay for medical costs not covered by the healthcare plan itself https://en.wikipedia.org/wiki/Consumer-driven_healthcare

PPO=Preferred Provider Organization — similar to an HMO, but with slightly higher fees, but more flexibility; the network of an HMO remains, but consumers are able to receive discounted insurance coverage outside of the network

MHPAEA=Mental Health Parity and Addiction Equity Act — a federal law enacted in 2008 which attempts to bring a more equal level of coverage to mental health and substance use disorder treatment and prevent limitation compared to medical and surgical benefits.

IFR=Interim Final Rule — proposed rule which goes into effect immediately and for which public comment is sought afterward.

DCN=Document Control Number

PICA=This is only a reference to typeface and type alignment on the CMS-1500 form. The blocks and the line are used for alignment assistance when the form is being digitally processed.

ESI=Express Scripts, Inc. — a company which manages pharmacy benefits for various organizations

NUBC=National Uniform Billing Committee — an organization which created a single, nationally used health care billing form; source of the UB-04 form https://www.nubc.org/about-nubc

CMS-1450=Also known as UB-04, this is a billing form used by institutional healthcare providers, most often Medicare and Medicaid https://www.cms.gov/Medicare/Billing/ElectronicBillingEDITrans/15_1450

List of CMS forms: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List

CMS=Centers for Medicare and Medicaid Services https://www.cms.gov/

Healthcare Quality Review: 1) Prospective review — An advance review of treatment plan to ensure appropriate care. Often used to discern “medically unnecessary” procedures, leading to denial of coverage/care. 2) Concurrent review — Monitoring and review of treatment as it occurs to ensure the most efficient and effective care. This stage usually aims to reduce denials of coverage. 3) Retrospective review — Post care/procedure/treatment review which aids in deciding confirmation, denial, and amount of payment & reimbursement. https://en.wikipedia.org/wiki/Utilization_management

E/M=Evaluation and management — this term is usually used in conjunction with psychotherapy services

ACA=Affordable Care Act or Patient Protection and Affordable Care Act, also known as “Obamacare” for the president who signed the act into law in 2010. It attempts to protect patients’ rights to fair and affordable health care and do so in an easily understandable manner. https://www.healthcare.gov/glossary/patient-protection-and-affordable-care-act/

HCERA=Health Care & Education Reconciliation Act of 2010 — a bill signed by President Barack Obama 10 days after the PPACA, making changes to the PPACA, and attempting to enact student loan reform. https://www.congress.gov/bill/111th-congress/house-bill/4872

I originally published this article here: https://medium.com/@minotaur.information/health-care-glossary-d43b22943ff5