Medical program certified or endorsed to provide services to members of a managed care plan or beneficiaries of a federal program (e.g., Medicare, TRICARE).

Modifier used by physicians who provide medical services in health professional shortage areas (HPSAs) that became effective January 1, 2006. Previously, two modifiers (QB and QU) distinguished between physicians providing HPSA services in rural areas and those providing HPSA services in urban areas. These are no longer used.

Proceeding for settling a dispute in which disputes are given to a third party or panel of experts to hear two sides of the story and who has power to make a legal binding decision for both parties on the case.

***

US: Arbitration: A form of alternative dispute resolution where an unbiased person or panel renders an opinion as to responsibility for or extent of a loss.

***

UK: An alternative to going to court for the settlement of a dispute. An independent arbitrator hears the case and makes an award in accordance with the Arbitration Act 1996. See ALTERNATIVE DISPUTE RESOLUTION.

****

An alternative to litigation by submitting a dispute to the judgment of a specified number of disinterested persons called “arbitrators,” whose decision called an “award” is binding on the parties. (I)Form of Alternative Dispute Resolution (II) Alternative to court room litigation (III) Parties submit their disputes to a NEUTRAL third party called the Arbitrator (s) or Arbiter (s) for resolution (IV) Binding dispute resolution, equivalent to litigation in the courts.

***

UK: an alternative to litigation for the settlement of insurance disputes; contracts often specify the place of arbitration in the event of a dispute.

Local (city or county) organization, funded under the federal Older Americans Act, that plans and coordinates various social and health service programs for persons 60 years of age or more. These needs include adult day care, skilled nursing care/therapy, transportation, personal care, respite care, and meals. The network of AAA offices consists of more than 600 approved agencies.

Software program created by the Office of the Inspector General (OIG) that helps to access provider claims data and to limit the need for the OIG to send multiple requests to insurance carriers for claims information. It can assist in detection of aberrant billing practices of providers.

In workers’ compensation cases, a criterion for determining liability, or whether a claim is or is not compensable. AOE refers to how the activity of work led to the injury in question. It is one of the legal tests that must be met for a medical condition to be covered by workers’ compensation insurance. COE refers to how the activity the employee was engaged in at the time of injury must grow out, or be incidental to, the employment.

In the Medicare program, the average number of days for a patient’s DRG inpatient hospital stay. This figure is used to determine payment for outlier cases and to predict occupancy rates. To obtain this number, use this formula: total number of patient days divided by (÷) the total number of hospital admissions for a specific time period. It is also known as average length of stay (ALOS).