Under the Health Insurance Portability and Accountability Act (HIPAA), means the sharing, employment, application, utilization, examination, or analysis of individually identifiable health information within an entity that maintains such information.

Cross-reference phrase used in ICD-9-CM, Volume 1, Tabular List, that follows a main term description indicating that an additional code should be used if the information is available to provide a more complete picture of the diagnosis.

Under the Health Insurance Portability and Accountability Act (HIPAA), disclosure is when a patient’s medical information is released to an individual or entity outside of the medical practice’s organization and use is when information is shared within the medical office to facilitate patient treatment.

Method used by insurance companies and managed care plans to establish their fee schedules in which three fees are considered in calculating payment: (1) The usual fee is the fee typically submitted by the physician, (2) the customary fee falls within the range of usual fees charged by providers of similar training in a geographical area, and (3) the reasonable fee meets the aforementioned criteria or is considered justifiable because of special circumstances.

Public-private coalition for reducing health care administrative costs through the standardization and electronic exchange of health care data.

Philosophical view or doctrine of ethics that the purpose of all action should be to bring about the greatest happiness for the greatest number of people and that the value of anything is determined by its utility.

Measurement of the frequency that members of a health insurance group use the services or procedures of a particular benefit plan, stated by average number of claims per insured over a specific time period.
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How much a covered group uses a particular insurance plan or program.

Program that replaced the Professional Standards Review Organization (PSRO) program. See Quality Improvement Organization (QIO) program .

Process and procedures implemented to administer the use of health care services in the hospital by evaluating quality of care and establishing appropriateness and medical necessity for services. It ensures maximum medical care resource use and helps reduce health care spending. Examples of UM are preadmission certifications, admission reviews, concurrent reviews, focused reviews, individual case management, discharge planning, retrospective reviews, provider profiling, and second surgical opinions.