Diagnosis-related group (DRG) system that is an enhancement of the original DRGs. It includes groupings for pediatric and maternity cases and services for HIV-related conditions and other special cases.

Insurance policy provision in which the deductible is met by a collection of eligible expenses incurred for any variety of covered claims within a given time period.

In a managed care contract, a flat fee charged daily by a facility (per diem rate) or for a total hospital stay. For submitting a Uniform Bill (UB-04) claim, revenue codes are 0100 (all-inclusive room and board plus ancillary) and 0101 (all-inclusive room and board). This is commonly billed by state psychiatric hospitals.

State system that helps in determining equal uniform prices on medical and hospital services across all providers and all public and private payers, for instance, a common fee schedule. Also referred to as all-payer system.

1. Health insurance purchasing entity (public or private) that enrolls subscribers or members within a given region, collects premiums, enforces rules that manage health plans, and purchases subscribers’ or members’ insurance from participating health plans. 2. Organization or group of employers that pools resources to buy health care goods and services. Also known as a purchasing group . See consumer health alliances. 3. Formal, mutual arrangement of companies, providers, or institutions, established to further common goals.

Health care provider who is not licensed as a doctor of medicine or osteopathy (e.g., nurse practitioner, physician assistant, chiropractor, medical assistant).