Data needed about the onset and history of a specific illness so that a managed care plan may establish if benefits are available for treatment.

Nonstock, nonprofit membership association of life insurance companies of the United States and Canada that provides information and database management services to the financial services industry. Organized in 1902, MIB’s core fraud protection services protect insurers, policyholders, and applicants from attempts to conceal or omit information material to the sound and equitable underwriting of life, health, disability, and long-term care insurance. Fair pricing of insurance products is dependent on accurate “risk assessment,” “risk classification,” and “risk selection.” A determination of these factors begins with the assurance of accurate health information supplied on the insurance application concerning the proposed insured.

Employee who works for a physician or in a health care facility and handles source documents, codes procedures and diagnoses, processes insurance claims, and follows up on delayed reimbursement and delinquent accounts. Also known as an insurance claims processor, medical biller , or reimbursement specialist . Also see insurance billing specialist.

System employed by health insurance and managed care plans that uses administration and policy and the individuals who make the decisions and supervise to achieve business objectives and reduce costs and use of health care services.

Phrase used in statistics that explains patients in the same diagnosis-related groups (DRGs) that are anticipated to have a set of clinical responses that result in a comparable pattern of use of medical services and supplies.

Medical care given only when an individual is ill with emphasis on the diagnosis and treatment of disease instead of health promotion and prevention of disease.

1. Performance of services and procedures required by the patient, indispensable, and consistent with the diagnosis in accordance with standards of good medical practice, performed at the proper level, and provided in the most appropriate setting. Medical necessity must be established (via diagnostic and/or other information presented on the individual claim under consideration) before the carrier may make payment. 2. Cal. Wel. & Inst. Code 14059.5 defines medical necessity when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain. Also see medically necessary care .

Specific nutritional procedures including assessment, counseling sessions, and interventions in the treatment of an acute or chronic illness, injury, or disease condition. MNT is provided by registered dietitians (RDs) and state-licensed dietitians.