Glossary of Terms in Case Management and Healthcare
AAPM&R - correct answer American Academy of Physical Medicine and Rehabilitation
ACCESS TO CARE - correct answer The ability and ease of clients to obtain healthcare when they
need it.
ACCESSIBLE - correct answer A term used to denote building facilities that are barrier-free thus
enabling all members of society safe access, including persons with physical disabilities.
ACCOUNTABLE CARE ORGANIZATION (ACO) - correct answer A set of healthcare providers
including primary care physicians, specialists, and hospitals that work together collaboratively
and accept collective accountability for the cost and quality of care delivered to a population of
patients.
ACCREDITATION - correct answer A standardized program for evaluating healthcare
organizations to ensure a specified level of quality, as defined by a set of national industry
standards.
ACTIONABLE TORT - correct answer A legal duty, imposed by statute or otherwise, owing by
defendant to the one injured.
ACTIVE LISTENING - correct answer A structured way of communication and interacting in
which one is actively engaged with the speaker primarily through focused attention and
suspension of one's own frame of reference, biases, distractions and judgment.
ACTIVITIES OF DAILY LIVING (ADLS) - correct answer Routine activities an individual tends to do
every day for self-care and normal living.
ACTIVITY LIMITATIONS - correct answer Difficulties an individual may have in executing
activities.
ACTUAL VALUE - correct answer Also referred to as real value. Measures the worth one derives
from using or consuming a good, product, service or an item.
ACTUARIAL STUDY - correct answer Statistical analysis of a population based on its utilization of
healthcare services and demographic trends of the population.
ACTUARY - correct answer A trained insurance professional who specializes in determining
policy rates, calculating premiums, and conducting statistical studies.
ACUITY - correct answer Complexity and severity of the client's health/medical condition.
ACUTE CARE - correct answer The acute care delivery systems focus on treating sudden and
acute episodes of illness such as medical and surgical management or emergency treatment.
,ADA - correct answer Americans with Disabilities Act of 1990
ADA AMENDMENTS ACT (ADAAA) - correct answer Americans with Disabilities Act
Amendments Act of 2008
ADL - correct answer Activities of Daily Living.
Activities of Daily Living (ADLs) - correct answer Routine activities carried out for personal
hygiene and health and for operating a household. ADLs include feeding, bathing, showering,
dressing, getting in or out of bed or a chair, and using the toilet.
Adaptive Behavior - correct answer The effectiveness and degree to which an individual meets
standards of self-sufficiency and social responsibility for his/her age-related cultural group.
Adherence - correct answer The extent to which a person's behaviour--taking medication,
following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations
[e.g., health regimen] from a health care provider (Sabate, 2003).
Adhesive Contract - correct answer A contract between two parties where one party with
stronger bargaining power sets the terms and conditions and the other party, which is the
weaker of the two with little to no ability to negotiate, must adhere to the contract and is
placed in a 'take it or leave it' position (Cornell University Law School, Legal Information
Institute, accessed 6/4/2015).
Adjusted Clinical Group® (ACG) System - correct answer Developed by the School of Public
Health at Johns Hopkins University, this system clusters clients into homogenous groups (102
discrete groups) based on a unique approach to measuring morbidity to ultimately improve
accuracy and fairness in evaluating healthcare provider performance, identifying clients at high
risk, forecasting healthcare utilization, and setting equitable payment structure and rates for
the providers of care. The System accounts for the burden of morbidity in a client population
based on disease patterns, age, and gender and relies on the diagnostic and/or pharmaceutical
code information found in insurance claims or other computerized client health records (The
Johns Hopkins University, 2010).
Adjuster - correct answer A person who handles claims (also referred to as Claims Service
Representative).
Administrative Law - correct answer That branch of public law that deals with the various
organizations of federal, state, and local governments which prescribes in detail the manner of
their activities.
Administrative Services Only (ASO) - correct answer An insurance company or third party
administrator (TPA) that delivers administrative services to an employer group. This usually
requires the employer to be at risk for the cost of healthcare services provided, which the ASO
processes and manages claims.
,Admission Certification - correct answer A form of utilization review in which an assessment is
made of the medical necessity of a client's admission to a hospital or other inpatient facility.
Admission certification ensures that clients requiring a hospital-based level of care and length
of stay appropriate for the admission diagnosis are usually assigned and certified and payment
for the services are approved.
Admission Review - correct answer A review that occurs within 24 hours of a client's admission
to a healthcare facility (e.g., a hospital) or according to the time frame required in the
contractual agreement between the healthcare provider and the health insurance plan. This
review ensures that the client's care in an inpatient setting is necessary, based on the client's
health condition and intensity of the services needed.
Advance Directive - correct answer Legally executed document that explains the client's
healthcare related wishes and decisions. It is drawn up while the client is still competent and is
used if the client becomes incapacitated or incompetent.
Adverse Events - correct answer Any untoward occurrences, which under most conditions are
not natural consequences of the client's disease process or treatment outcomes.
Advocacy - correct answer The act of recommending, pleading the cause of another; to speak
or write in favor of. (CMSA Standards of Practice, 2010, p 24)
Advocate - correct answer A person or agency who speaks on behalf of others and promotes
their cause.
Affect - correct answer The observable emotional condition of an individual at any given time.
Affidavit - correct answer A written statement of fact signed and sworn before a person
authorized to administer an oath.
Aggregated Diagnosis Groups (ADGs) - correct answer A grouping of diagnosis codes that are
similar in terms of severity and likelihood of persistence in a client's health condition over time.
ADG - correct answer A total of 32 ADG clusters used to classify individual diseases or
conditions based on criteria including likely persistence of diagnosis, severity of illness, etiology,
diagnostic certainty, and need for specialty care interventions.
AGREED MEDICAL EXAMINATION - correct answer An evaluation conducted by a provider
selected by agreement between an injured workers' attorney and the insurance claims
administrator to resolve disputes and determine contributions to disability.
AHA - correct answer American Heart Association.
AHRQ - correct answer Agency for Healthcare Research and Quality.
ALGORITHM - correct answer The chronological delineation of the steps in, or activities of,
client care to be applied in the care of clients as they relate to specific conditions/situations.
, ALTERNATE LEVEL OF CARE - correct answer A level of care that can safely be used in place of
the current level, determined based on the acuity and complexity of the client's condition and
the type of needed services and resources.
AMA - correct answer American Medical Association.
AMBULATORY PAYMENT CLASSIFICATION (APC) SYSTEM - correct answer An encounter-based
classification system for outpatient reimbursement, including hospital-based clinics, emergency
departments, observation, and ambulatory surgery, with payment rates based on categories of
services that are similar in cost and resource utilization.
ANA - correct answer American Nurses Association.
ANCC - correct answer American Nurses Credentialing Center.
ANCILLARY SERVICES - correct answer Other diagnostic and therapeutic services involved in the
care of clients other than nursing or medicine, including respiratory, laboratory, radiology,
nutrition, physical and occupational therapy, and pastoral services.
APC - correct answer See ambulatory payment classification.
APPEAL (CARE PROVISION RELATED) - correct answer The formal process or request to
reconsider a decision made not to approve an admission or healthcare services, reimbursement
for services rendered, or a client's request for postponing the discharge date and extending the
length of stay.
APPEAL (LEGAL IN NATURE) - correct answer The process whereby a court of appeals reviews
the record of written materials from a trial court proceeding to determine if errors were made
that might lead to a reversal of the trial court's decision.
APPROPRIATENESS OF SETTING - correct answer Used to determine if the level of care needed
is being delivered in the most appropriate and cost-effective setting possible.
APPROVAL - correct answer To offer or receive affirmation, sanction, or agreement about a
decision, action, service, treatment, or intervention, particularly in health insurance, it implies
agreement to reimburse the provider for the service.
APPROVED CHARGE - correct answer The amount Medicare pays a physician based on the
Medicare fee schedule, with the possibility for physicians to bill beneficiaries for an additional
amount, subject to the limiting charge allowed.
ASO - correct answer See administrative services only.
ASSESSING - correct answer The process of collecting in-depth information about a client and
their support system to identify needs and decide upon the best case management services.
AAPM&R - correct answer American Academy of Physical Medicine and Rehabilitation
ACCESS TO CARE - correct answer The ability and ease of clients to obtain healthcare when they
need it.
ACCESSIBLE - correct answer A term used to denote building facilities that are barrier-free thus
enabling all members of society safe access, including persons with physical disabilities.
ACCOUNTABLE CARE ORGANIZATION (ACO) - correct answer A set of healthcare providers
including primary care physicians, specialists, and hospitals that work together collaboratively
and accept collective accountability for the cost and quality of care delivered to a population of
patients.
ACCREDITATION - correct answer A standardized program for evaluating healthcare
organizations to ensure a specified level of quality, as defined by a set of national industry
standards.
ACTIONABLE TORT - correct answer A legal duty, imposed by statute or otherwise, owing by
defendant to the one injured.
ACTIVE LISTENING - correct answer A structured way of communication and interacting in
which one is actively engaged with the speaker primarily through focused attention and
suspension of one's own frame of reference, biases, distractions and judgment.
ACTIVITIES OF DAILY LIVING (ADLS) - correct answer Routine activities an individual tends to do
every day for self-care and normal living.
ACTIVITY LIMITATIONS - correct answer Difficulties an individual may have in executing
activities.
ACTUAL VALUE - correct answer Also referred to as real value. Measures the worth one derives
from using or consuming a good, product, service or an item.
ACTUARIAL STUDY - correct answer Statistical analysis of a population based on its utilization of
healthcare services and demographic trends of the population.
ACTUARY - correct answer A trained insurance professional who specializes in determining
policy rates, calculating premiums, and conducting statistical studies.
ACUITY - correct answer Complexity and severity of the client's health/medical condition.
ACUTE CARE - correct answer The acute care delivery systems focus on treating sudden and
acute episodes of illness such as medical and surgical management or emergency treatment.
,ADA - correct answer Americans with Disabilities Act of 1990
ADA AMENDMENTS ACT (ADAAA) - correct answer Americans with Disabilities Act
Amendments Act of 2008
ADL - correct answer Activities of Daily Living.
Activities of Daily Living (ADLs) - correct answer Routine activities carried out for personal
hygiene and health and for operating a household. ADLs include feeding, bathing, showering,
dressing, getting in or out of bed or a chair, and using the toilet.
Adaptive Behavior - correct answer The effectiveness and degree to which an individual meets
standards of self-sufficiency and social responsibility for his/her age-related cultural group.
Adherence - correct answer The extent to which a person's behaviour--taking medication,
following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations
[e.g., health regimen] from a health care provider (Sabate, 2003).
Adhesive Contract - correct answer A contract between two parties where one party with
stronger bargaining power sets the terms and conditions and the other party, which is the
weaker of the two with little to no ability to negotiate, must adhere to the contract and is
placed in a 'take it or leave it' position (Cornell University Law School, Legal Information
Institute, accessed 6/4/2015).
Adjusted Clinical Group® (ACG) System - correct answer Developed by the School of Public
Health at Johns Hopkins University, this system clusters clients into homogenous groups (102
discrete groups) based on a unique approach to measuring morbidity to ultimately improve
accuracy and fairness in evaluating healthcare provider performance, identifying clients at high
risk, forecasting healthcare utilization, and setting equitable payment structure and rates for
the providers of care. The System accounts for the burden of morbidity in a client population
based on disease patterns, age, and gender and relies on the diagnostic and/or pharmaceutical
code information found in insurance claims or other computerized client health records (The
Johns Hopkins University, 2010).
Adjuster - correct answer A person who handles claims (also referred to as Claims Service
Representative).
Administrative Law - correct answer That branch of public law that deals with the various
organizations of federal, state, and local governments which prescribes in detail the manner of
their activities.
Administrative Services Only (ASO) - correct answer An insurance company or third party
administrator (TPA) that delivers administrative services to an employer group. This usually
requires the employer to be at risk for the cost of healthcare services provided, which the ASO
processes and manages claims.
,Admission Certification - correct answer A form of utilization review in which an assessment is
made of the medical necessity of a client's admission to a hospital or other inpatient facility.
Admission certification ensures that clients requiring a hospital-based level of care and length
of stay appropriate for the admission diagnosis are usually assigned and certified and payment
for the services are approved.
Admission Review - correct answer A review that occurs within 24 hours of a client's admission
to a healthcare facility (e.g., a hospital) or according to the time frame required in the
contractual agreement between the healthcare provider and the health insurance plan. This
review ensures that the client's care in an inpatient setting is necessary, based on the client's
health condition and intensity of the services needed.
Advance Directive - correct answer Legally executed document that explains the client's
healthcare related wishes and decisions. It is drawn up while the client is still competent and is
used if the client becomes incapacitated or incompetent.
Adverse Events - correct answer Any untoward occurrences, which under most conditions are
not natural consequences of the client's disease process or treatment outcomes.
Advocacy - correct answer The act of recommending, pleading the cause of another; to speak
or write in favor of. (CMSA Standards of Practice, 2010, p 24)
Advocate - correct answer A person or agency who speaks on behalf of others and promotes
their cause.
Affect - correct answer The observable emotional condition of an individual at any given time.
Affidavit - correct answer A written statement of fact signed and sworn before a person
authorized to administer an oath.
Aggregated Diagnosis Groups (ADGs) - correct answer A grouping of diagnosis codes that are
similar in terms of severity and likelihood of persistence in a client's health condition over time.
ADG - correct answer A total of 32 ADG clusters used to classify individual diseases or
conditions based on criteria including likely persistence of diagnosis, severity of illness, etiology,
diagnostic certainty, and need for specialty care interventions.
AGREED MEDICAL EXAMINATION - correct answer An evaluation conducted by a provider
selected by agreement between an injured workers' attorney and the insurance claims
administrator to resolve disputes and determine contributions to disability.
AHA - correct answer American Heart Association.
AHRQ - correct answer Agency for Healthcare Research and Quality.
ALGORITHM - correct answer The chronological delineation of the steps in, or activities of,
client care to be applied in the care of clients as they relate to specific conditions/situations.
, ALTERNATE LEVEL OF CARE - correct answer A level of care that can safely be used in place of
the current level, determined based on the acuity and complexity of the client's condition and
the type of needed services and resources.
AMA - correct answer American Medical Association.
AMBULATORY PAYMENT CLASSIFICATION (APC) SYSTEM - correct answer An encounter-based
classification system for outpatient reimbursement, including hospital-based clinics, emergency
departments, observation, and ambulatory surgery, with payment rates based on categories of
services that are similar in cost and resource utilization.
ANA - correct answer American Nurses Association.
ANCC - correct answer American Nurses Credentialing Center.
ANCILLARY SERVICES - correct answer Other diagnostic and therapeutic services involved in the
care of clients other than nursing or medicine, including respiratory, laboratory, radiology,
nutrition, physical and occupational therapy, and pastoral services.
APC - correct answer See ambulatory payment classification.
APPEAL (CARE PROVISION RELATED) - correct answer The formal process or request to
reconsider a decision made not to approve an admission or healthcare services, reimbursement
for services rendered, or a client's request for postponing the discharge date and extending the
length of stay.
APPEAL (LEGAL IN NATURE) - correct answer The process whereby a court of appeals reviews
the record of written materials from a trial court proceeding to determine if errors were made
that might lead to a reversal of the trial court's decision.
APPROPRIATENESS OF SETTING - correct answer Used to determine if the level of care needed
is being delivered in the most appropriate and cost-effective setting possible.
APPROVAL - correct answer To offer or receive affirmation, sanction, or agreement about a
decision, action, service, treatment, or intervention, particularly in health insurance, it implies
agreement to reimburse the provider for the service.
APPROVED CHARGE - correct answer The amount Medicare pays a physician based on the
Medicare fee schedule, with the possibility for physicians to bill beneficiaries for an additional
amount, subject to the limiting charge allowed.
ASO - correct answer See administrative services only.
ASSESSING - correct answer The process of collecting in-depth information about a client and
their support system to identify needs and decide upon the best case management services.
