Amount of services and procedures required from a health care system by a specific population of patients.

Invoices sent to the Medicare administrative contractor for medical review and payment determination at the request of the beneficiary because the patient disputes the provider’s opinion that the bill will not be paid by Medicare.

This phrase is used in managed care and is a technique or process used to match patient needs with a quality, cost-efficient atmosphere and at the same time influencing self-care to members, which lowers their needs for services and results in lower costs of care.

Phrase that refers to obstacles in getting medical care by patients who do not have the income to pay for health care services or obtain medical insurance.

Information that describes the characteristics of enrollee populations within a managed care entity. Demographic data includes but is not limited to age, sex, race/ethnicity, and primary language.

Data that describe specific characteristics about a patient such as name, address, date of birth, sex, and Social Security number. These data are usually obtained when the patient is either admitted to the hospital or seen for the first visit in a physician’s office.

Type of community rating that takes into consideration several statistical characteristics (e.g., age, geographic area, industry, sex of the population).

Pertaining to statistical descriptions including distribution, density, and vital statistics of populations such as age, births, deaths, marital status, income, and unemployment.

Projects and contracts that Centers for Medicare and Medicaid Services (CMS) has signed with various health care organizations. These contracts allow CMS to test various or specific attributes such as payment methodologies, preventive care, and social care and to determine if such projects/pilots should be continued or expanded to meet the health care needs of the nation. Demonstrations are used to evaluate the effects and impact of various health care initiatives and the cost implications to the public.