Terms & Acronyms
|Area Agency on Aging – Covers several Northern Michigan counties.
|Means the ability or the means necessary to read, write, modify, or communicate data/information or otherwise use any system resource. Barriers or lack thereof for persons in obtaining services. Access is more than having insurance coverage or the ability to pay for services. It is also determined by the availability of services, acceptability of services, cultural appropriateness, location, hours of operation, transportation needs, and cost.
|Assertive Community Treatment – a model of intensive, non-office- centered client services management, psychiatric care and other supportive services for adults with chronic mental illnesses. The ACT model is also used in serving children with long-term mental illnesses.
|American Disabilities Act
|Advanced Daily Living Skills – training in self-care, cooking, housekeeping and other skills needed in daily living, to enable consumers to function more independently. They encompass a broad range of activities, including maintaining personal hygiene, preparing meals, and managing household chores.
|Are administrative actions, and policies and procedures, to manage the selection, development, implementation, and maintenance of security measures to protect electronic protected health information and to manage the conduct of the covered entity’s workforce in relation to the protection of that information.
|Adult Foster Care – if an owner/operator is providing the following services, they are required to be licensed by the Department of Human Services (DHS) as an Adult Foster Care facility: Room and Board, Supervision, Personal Care, Protection. These services are paid for out of the residents’ SSI or SSD income. Types of Adult Foster Care Facilities include “Family Home” (a private residence with a maximum capacity of six. The licensee must be a member of the household and an occupant of the residence), “Small Group” (usually 6 beds, maximum of 12), “Large Group” (13-20 beds) and “Congregate Facility” (more than 20 beds). [ See also CLF].
|Application for Proposal
|Average Length of Stay – average duration of an episode of care for patients, e.g. in a hospital or residential program.
|American National Standards Institute
|Association of Retarded Citizens
|Administrative Services Only – A relationship between an insurance company or other management entity and a self-funded plan or group of providers in which the insurance company or management entity performs administrative services only, such as billing; practice management, marketing, and does not assume any risk.
|Alternate Treatment Order – an order from the Probate Court requesting an independent evaluation (“Alternative Treatment Report”) of an allegedly mentally ill adult prior to a commitment hearing, to determine if an alternative to hospitalization would be appropriate. Alternative Treatment Reports are prepared by NLCMHA staff.
|Means the corroboration that a person is the one claimed.
|Means the property that data or information is accessible and usable upon demand by an authorized person.
|Bay Area Transportation Authority
|Behavioral Health Carve-Out
|A “Carve-out” is a decision to purchase separately a service which is typically a part of an insurance or Health Maintenance Organization (HMO) plan.
|Basic Daily Living Skills – eating, bathing, toileting, etc.
|C & P
|Credentialing and Privileging – Credentialing is the system by which a hospital checks that its healthcare practitioners are properly qualified and grants them “rights” to perform duties that match their area of expertise.
|A method for payment to providers, common in most managed care arenas. Unlike the older fee-for-service arrangement, in which the provider is paid per procedure, capitation involves a prepaid amount per month to the provider per covered member (PMPM). The provider is then responsible for providing all contracted services (such as behavioral health) required by members of that group during that month – for the fixed fee, regardless of the amount of charges incurred. In such an arrangement, the provider is now at risk, picking up risk that the payer or employer used to have exclusively in fee-for-service or indemnity arrangements. Management services, too, may be capitated. In such contracts, the contracting party is required to provide all management services (pre-certification, utilization review, case management, discharge planning) required for the fixed fee, while the costs of treatment services are paid separately. This last model relating to management services is the way much managed behavioral healthcare is handled presently. A Managed Care Organization (MCO) will contract with an HMO or a major insurer to manage a behavioral health “carve out.” (See below). The MCO provides these management services for a fixed charge per member per month (PMPM) and subcontracts with providers, usually at a discounted fee-for-service rate, to serve the covered members.
|Capped Global Budget
|A fixed-dollar contract which ordinarily cannot be exceeded. May consist of funding from multiple sources, which are capped in total, not individually.
|A payer strategy in which a payer separates (“carves-out”) a portion of the benefit, such as behavioral health, and hires a managed behavioral health program (MBHP) or managed care organization (MCO) to provide these benefits. This permits the payer to create a behavioral health benefits package, get to market quicker with such a package, and provides greater control of their costs. Many HMOs and insurance companies adopt this strategy because they do not have in-house expertise related to behavioral health or to the service “carved out”.
|Commission on Accreditation of Rehabilitation Facilities – National Accrediting Body which accredits many types of CMH programs, not just rehabilitation agencies.
|Flat fee paid for a client’s treatment based on their diagnosis and/or presenting problem. For this fee the provider covers all of the services the client requires for a specific period of time. Also known as bundled rate, or Flat Fee-Per-Case. Very often used as an intervening step prior to Capitation. In this model, the provider is accepting significant risk, but does have considerable flexibility in how it meets the client’s needs. Keys to success in this model: (1) properly pricing case rate, if provider has control over it, and (2) securing a large volume of eligible clients.
|The geographic area served by a program.
|Child Caring Institution – facility licensed by, the Department of Human Services to provide institutional care as a “therapeutic community” for youngsters with emotional disturbances.
|Chief Executive Officer
|Chief Financial Officer
|Center One – the Behavioral Health Unit at Munson Medical Center.
|An individual up to the age at which one is legally recognized as an adult according to state or provincial law.
|Community Health Information Network – An integrated collection of computer and telecommunication capabilities that permit multiple providers, payers, employers, and related healthcare entities within a geographic area to share and communicate client, clinical, and payment information. Also known as Community Health Management Information System.
|Community Living Facility – an enhanced Adult Foster Care or Children’s Foster Care home under contract to a Department of Community Health (DCH) facility or a CMH Board to provide specialized 24-hour residential services; the home receives DCH or CMH funding over and above the residents’ SSI or SSD. Like all foster care homes, these must also be licensed by the Department of Human Services.
|Clinical or Critical Pathways
|A “map” of preferred treatment/intervention activities. Outlines the types of information needed to make a decision, the timelines for applying that information, and what action needs to be taken by whom. Provides a way to monitor care “in real time.” These pathways are developed by clinicians for specific diseases or events. Proactive providers are working now to develop these pathways for the majority of their interventions and developing the software capacity to distribute and store this information.
|Clubhouse (Club Cadillac or Traverse House)
|A rehabilitation service designed for adults with mental illness, which includes Psycho-Social programming such as: client choice (person-centered planning), equal opportunity to access services (regardless of diagnosis), environmental supports, formal and informal structures (participation on advisory councils), Medicaid covered services to be provided during the work-ordered day, member directed services, treatment planning, membership that is driven by consumer needs, flexible hours for services, symptom identification and care, competency building, work ordered day programs, vocational/employment. In addition, the program shall provide a sense of autonomy and convey a sense of dignity and respect to recipients.
|Chief Managed Care Officer
|Community Mental Health – program as defined in Chapter 2 of the Michigan Mental Health Code.
|Community Mental Health Services Program – A program operated under Chapter 2 of the Michigan Mental Health Code-Act 258 of 1974 as amended. There are 46 CMHSPs in Michigan that provide services in their local areas to people with mental illness and developmental disabilities.
|The date by which a covered entity must comply with a standard, implementation specification, requirement, or modification.
|A routine review by an internal or external utilization reviewer, during the course of a patient’s treatment, to determine if continued treatment is medically necessary. (See below.) This usually occurs for inpatient, residential, and partial hospitalization treatment, though it is becoming more frequent for outpatient treatment as well.
|Means the property that data or information is not made available or disclosed to unauthorized persons or processes.
|Continued Stay Review
|A review conducted by an internal or external auditor to determine if the current place of service is still the most appropriate to provide the level of care required by the client.
|When used to compare a provision of State law to a standard, requirement, or implementation specification adopted under this subchapter, means:
|Chief Operations Officer
|Can mean: a health plan, a health care clearinghouse, a health care provider who transmits any health information in electronic form in connection with a transaction.
|Continuous Quality Improvement – an organizational “culture” promoted by the leadership that encourages and empowers line staff to take responsibility for making proactive, ongoing improvements in the way they do work.
|Client Services Management (also called supports coordination”) assesses the basic life and human service needs of an individual with a chronic mental illness or developmental disability, links the person to what s/he needs, monitors the client’s receipt of planned services, and advocates on behalf of clients for needed services that are lacking in the community. Also includes supportive psychiatric evaluation, medication therapy, counseling, and crisis intervention as needed.
|Is an acceptance and respect for difference, a continuing self-assessment regarding culture, a regard for and attention to the dynamics of difference, engagement in ongoing development of cultural knowledge, and resources and flexibility within service models to work towards better meeting the needs of minority populations. An organization’s ability to recognize, respect, and address the unique needs, worth, thoughts, communications, actions, customs, beliefs, and values that reflect an individual’s racial, ethnic, religious, and/or social groups or sexual orientation.
|With respect to protected health information created or received by a business associate (in its capacity as the business associate of a covered entity) the combining of such protected health information by the business associate with the protected health information received by the business associate (in its capacity as a business associate of another covered entity) to permit data analyses that relate to the health care operations of the respective covered entities.
|Department of Community Health – State of Michigan
|Developmental Disability– a severe, chronic condition that meets all of the following requirements:
|Designated Record Set
|Direct treatment relationship
|Means a treatment relationship between an individual and a health care provider that is not an indirect treatment relationship.
|Means the release, transfer, provision of access to, or divulging in any other manner of information outside the entity holding the information.
|The Drop-in Center provides a place for individuals with mental and emotional problems to gather. It is run by and for consumers of the mental health system. It is a neutral environment, with no programs or treatments. It is a place where individuals can learn to live their lives again.
|Diagnostic and Statistical Manual of Mental Disorders– Contains the diagnostic codes used to identify disorders. These codes are also used in the billing of services for these disorders.
|Department of Social Services – State of Michigan. Now called the Department of Human Services (DHS).
|Usually refers to persons with both a mental illness and substance abuse problem, though sometimes refers to persons with mental illness and developmental disability.
|Electro Convulsive Therapy – Formerly known as electroshock, is a psychiatric treatment in which seizures are electrically induced in anesthetized persons for therapeutic effect. Its mode of action is unknown. Today, ECT is most often recommended for use as a treatment for severe depression which has not responded to other treatment, and is also used in the treatment of mania and catatonia.
|Electrocardiogram – A visual record of the heart’s electrical activity made using an electrocardiograph.
|Electronic storage media including memory devices in computers (hard drives) and any removable/transportable digital memory medium, such as magnetic tape or disk, optical disk, or digital memory card; or Transmission media used to exchange information already in electronic storage media. Transmission media include, for example, the Internet (wide-open), extranet (using internet technology to link a business with information accessible only to collaborating parties), leased lines, dial-up lines, private networks, and the physical movement of removable/transportable electronic storage media. Certain transmissions, including of paper, via facsimile, and of voice, via telephone, are not considered to be transmissions via electronic media, because the information being exchanged did not exist in electronic form before the transmission.
|Educable Mentally Impaired
|Means the use of an algorithmic process to transform data into a form in which there is a low probability of assigning meaning without use of a confidential process or key.
|Any person eligible, as either a subscriber or a dependent, for services in a health plan. (Synonyms: beneficiary, eligible individual, member, participant.)
|Exclusive Provider Organization (EPO)
|A type of provider organization similar to an HMO. Such entities often use a Primary Care Provider as gatekeepers, often capitate providers, have a limited provider panel, and use an authorization system. These entities are “exclusive” because the member must remain within the network to receive benefits. The main difference from an HMO is that EPOs are generally regulated under insurance regulations rather than HMO regulations. Many states refuse to permit the development of EFOS, claining that they are really HMOs.
|Means the physical premises and the interior and exterior of a building(s).
|A listing of fees or allowances for specified medical or health procedures, which usually represent the mazimum amounts the program or plan will pay for specified procedures. (Also known as table of allowances).
|Family Independence Agency – State of Michigan. Now known as DHS (MDHS) Department of Human Services – State of Michigan.
|Foundation for Mental Health
|A private non-profit organization currently investing in housing for consumers of NLCMHA and other agencies.
|Family Foster Care – a type of foster care home in which the licensed provider actually lives in the home and cares for the residents (as opposed to a Group Home); Family Foster Care homes can be licensed for up to three beds.
|Freedom of Information Act – Michigan – The Freedom of Information Act regulates and sets requirements for the disclosure of public records by all “public bodies” in the state.
|Fiscal Year – A 12-month period at the end of which all accounts are completed in order to provide a statement of a company’s, organization’s, or government’s financial condition, or for tax purposes. A fiscal year does not necessarily correspond to a calendar year: NLCMH’s fiscal year is from October 1 to September 30.
|Grievance and Appeal – Process for consumers to appeal services that are: denied, delayed, reduced, terminated or suspended.
|An individual, usually a clinician, who controls the access to healthcare services for members of a specific group. In many HMO settings, this gatekeeper is the Primary Care Physician (PCP) or his/her staff. In other health care delivery systems (and in HMOs in which behavioral health services are contracted out), the gatekeeper is often a case manager of the behavioral health organization.
|GTP Industries – Provides supportive work experiences to people with disabilities.
|Health Care Financing Administration – now known as: CMS-Centers for Medicare & Medicaid Services.
|Care, services, or supplies related to the health of an individual. Health care includes, but is not limited to: Preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, service, assessment, or procedure with respect to the physical or mental condition, or functional status, of an individual or that affects the structure or function of the body; and sale or dispensing of a drug, device, equipment, or other item in accordance with a prescription.
|Health Care Operations
|Means any of the following activities of the covered entity to the extent that the activities are related to covered functions;
|Health care provider
|A provider of medical or health services and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business.
|Any information, whether oral or recorded in any form or medium that: is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse: and relates to the past, present or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual.
|Health Insurance Issuer
|Means an insurance company, insurance service, or insurance organization (including an HMO) that is licensed to engage in the business of insurance in a State and is subject to State law that regulates insurance.
|Department of Health and Human Services – State of Michigan.
|Homicidal Ideation – the forming of homicidal ideas.
|Health Insurance Portability and Accountability Act of 1996 – The Act provides for improved portability of health benefits and enables better defense against abuse and fraud, reduces administrative costs by standardizing format of specific healthcare information to facilitate electronic claims, directly addresses confidentiality and security of patient information-electronic and paper-based, and mandates “best effort” compliance.
|Human Immunodeficiency Virus – The virus that causes acquired immune deficiency syndrome (AIDS).
|Health Maintenance Organization – an alternative to traditional healthcare insurance, linking the consumer with specific providers and clinics to keep him/her health (through covered checkups) and take care of him/her when ill. An HMO contracts with health care providers on a capitation basis. HMO’s are licensed by the State, and must offer mental health care as part of their package of services. For HIPAA, this means a federally qualified HMO, an organization recognized as an HMO under State law, or a similar organization regulated for solvency under State law in the same manner and to the same extent as such an HMO.
|Home of Your Own
|An unlicensed residential arrangement through which services are provided to the consumer in their own home or apartment. Services are intended to enhance existing skills of the consumers and promote community integration and access. In this type of arrangement, the consumer is able to select a new Provider without affecting their ability to reside in the home or apartment.
|Department of Housing & Urban Development
|I & R
|Information & Referral
|Interdisciplinary Team of mental health professionals (i.e. including more than one discipline-psychiatry, social work, psychology, nursing, occupational therapy, etc.).
|Individual Educational Plan – In the United States an Individualized Education Program, commonly referred to as an IEP, is mandated by the Individuals with Disabilities Education Act (IDEA). An IEP claims to be designed to meet the unique educational needs of one child, who may have a disability, as defined by federal regulations. The IEP helps children reach educational goals easier than they otherwise would. In all cases the IEP must be tailored to the individual student’s needs as identified by the IEP evaluation process, and must especially help teachers and related service providers understand the student’s disability and how the disability affects the learning process. The IEP should describe how the student learns, how the student best demonstrates that learning and what teachers and service providers will do to help the student learn more effectively. Key considerations in developing an IEP include assessing students in all areas related to the known disabilities, simultaneously considering ability to access the general curriculum, considering how the disability affects the student’s learning, developing goals and objectives that correspond to the needs of the student, and ultimately choosing a placement in the least restrictive environment possible for the student. Often, the results of an IEP, which must be regularly maintained and updated over the student’s primary educational years result in a mix of “normal”, mainstream classes, and specialized classes or sub-specialties taught by a specifically-trained individual, such as a special education teacher, sometimes within a resource room. An IEP is meant to ensure that students who aren’t inherently qualified only for special education classes, but are instead able to participate in at least several if not mainstream classes, aren’t unnecessarily and unilaterally shunted into the special education classrooms or special schools. It is meant to give the student a chance to participate in “normal” school culture and academics as much as is possible for that individual student. In this way, the student is able to have specialized assistance only when such assistance is absolutely necessary, and otherwise maintains the freedom to interact with and participate in the activities of his or her more general school peers.
|Independent Living Program provides supports and training to support persons living in independent living.
|Means specific requirements or instructions for implementing a standard.
|Indirect Treatment Relationship
|Means a relationship between an individual and a health care provider in which;
|The person who is the subject of protected health information.
|Individually Identifiable Health Information
|Information that is a subset of health information, including demographic information collected from an individual, and: is created or received by a health care provider, health plan, employer, or health care clearinghouse; and relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and that identifies the individual; or with respect to which there is a reasonable basis to believe the information can be used to identify the individual.
|Means an interconnected set of information resources under the same direct management control that shares common functionality. A system normally includes hardware, software, information, data, applications, communications, and people.
|A decision made be a person served that is based on sufficient experience and knowledge, including exposure, awareness, interactions, or instructional opportunities, so that the choice is made with adequate awareness of the alternatives and consequences of the options available.
|Participation in the mainstream of community life. Participation means that the person served maintains social relationships with family members, peers, and others in the community who do not have disabilities. In addition, the persons served have equal access to and full participation in community resources and activities available to the general public.
|Means the property that data or information have not been altered or destroyed in an unauthorized manner.
|Individual Plan of Service – the document developed with the consumer and their identified support system (when appropriate), which verifies the services to be provided to the consumer.
|IS or IT
|Information Systems or Information Technology – computer systems and their software.
|Intermediate School District – in Grand Traverse Country; “Traverse City Area School District”
|Joint Commission on Accreditation of Healthcare Organizations – National Accrediting Body
|Joint Executive Team CEOs from GLCMH, NCCMH, and WMCMH
|Joint Operating Agreement between GLCMH, NCCMH, WMCMH
|Limited English Proficiency – individuals who cannot speak, write, read or understand the English language at a level that permits them to interact effectively with health care providers and social service agencies.
|Length of Stay – duration of an episode of care for patients, e.g. in a hospital, residential program.
|Michigan Association for Emotionally Disturbed Children – parent advocacy organization.
|Michigan Association of Counties
|Michigan Association of Community Mental Health Boards – a Lansing-based advocacy organization of statewide CMH Boards. GLCMH is a member.
|Means software, for example, a virus, designed to damage or disrupt a system.
|Managed Health Care
|A system that uses financial incentives and management controls to direct patients to providers who are responsible for giving appropriate care in cost-effective treatment settings. Such systems are created to control the cost of health care.
|Managed Behavioral Health Program-An organization that assumes the responsibility for managing the behavioral health benefit for an employer or payer organization. The management may range from utilization management services to the actual provision of the services through its own organization or provider network. Reimbursement may be on a fee-for-service, shared risk, or full-risk basis. Also called a Managed Care Organization or an MCO, though this is a specialty MCO.
|Managed Care Advisory Committee Board representatives from all three Boards. (GLCMH, NCCMH, WMCMH)
|Managed Care Organization
|Managed Community Treatment Team – Case Management for Adults with Mental Illness
|Michigan Department of Community Health – State of Michigan
|Services or supplies which meet the following tests: They are appropriate and necessary for the symptoms, diagnosis, or treatment of the medical condition; They are provided for the diagnosis or direct-care and treatment of the medical condition; They meet the standards of good medical practice within the medical community in the service area; They are not primarily for the convenience of the plan member or a plan provider and; They are the most appropriate level or supply of service which can safely be provided.
|Mental Illness (MI-A=adults with mental illness, MI-C=children with mental illness, MI-DD=mental illness and Developmentally Disabled-“dually diagnosed”.)
|Services for persons who are mentally iII and chemically abusing – “dually diagnosed”
|Management Information System – computer-based data system responsible for generating data used in the management of the organization.
|Michigan Mission Based Performance Indicator System – The system designed by MDCH in collaboration with the MACMHB, to clearly delineate and manage toward the specific dimensions of quality which must be addressed by the Public Mental Health System as reflected in the Mission statements form Delivering the Promise and the needs and concerns expressed by consumers and other citizens of Michigan.
|Munson Medical Center – Traverse City hospital
|Michigan Mental Health Code
|Modify or Modification
|Refers to a change adopted by the Secretary of Health and Human Services, through regulation, to a standard or an implementation specification.
|Means, in the context of a comparison of a provision of State law and a standard, requirement, or implementation specification adopted under subpart E of part 164 of this subchapter, a State law that meets one or more of the following criteria:
|National Alliance for the Mentally Ill
|Natural Supports can be defined as personal ways of getting help for things an individual cannot do on his/her own. A “natural” support is a parent, relative, neighbor, church, or close friend with whom someone already has an existing and trusting relationship.
|North Central Community Mental Health
|Northwest Community Mental Health Affiliation – the affiliation formed by North Central, Great Lakes, and West Michigan CMH.
|A health plan that contracts with multiple physician groups or other providers to deliver health care to members. Generally limited to large single or multi-specialty groups. Distinguished from group model plans that contract with a single medical group, from IPAs that contract through an intermediary, and from direct contract plans that contract with individual physicians in the community. Many current behavioral healthcare networking efforts are attempts to create service systems along this line, or to integrate behavioral healthcare practices into such entities.
|National Institutes for Mental Health
|Omnibus Budget Reconciliation Act – Federal legislation; refers to the Nursing Home Reform Act which requires that all persons with a MI or developmental disability who apply for nursing home care or live in nursing homes, be evaluated for their mental health needs.
|Outpatient Psychiatric Clinic – term usually used to refer to clinics, whether public or private, that are approved for reimbursement by private insurers.
|Office of Recipient Rights
|Benefits supplied by a plan to its subscribers or enrollees when they need services outside the geographic limits of the HMO. These benefits usually include emergency care benefits, plus low fee-for-service payments for non-emergency care.
|P & A
|Michigan Protection and Advocacy Service – an independent agency of State government charged with representing the interests of citizens of all ages who are mentally ill or developmentally disabled, and pursuing all legal remedies to ensure their civil rights and rights as recipients of public mental health services.
|Michigan Public Act – laws passed by the Michigan Legislature.
|Means confidential authentication information composed of a string of characters.
|Person Centered Planning – means a process for planning and supporting the individual receiving services that builds upon the individual’s capacity to engage in activities that promote community life and that honors the individual’s preferences, choices, and abilities. The person-centered planning process involves families, friends, and professionals as the individual desires or requires.
|Primary Care Physician/Provider – A Primary Care Provider such as a family practitioner, internist, pediatrician and sometimes an OB/GYN. Generally, a PCP supervises, coordinates, and provides medical care to members of a plan. The PCP may initiate all referrals for specialty care. Within behavioral health, Case Managers are often the PCP.
|Protected Health Information – individually identifiable health information transmitted or maintained in any form. Protected Health Information excludes individually identifiable health information in: Education records covered by the Family Educational Right and Privacy Act, employment records held by a covered entity in its role as an employer.
|Prepaid Health Plan (otherwise known as the MCO) CMHSP organizations that manage specialty health care services under the Michigan Medicaid Waiver Program for Specialty Services as provided for in 42 CFR part 401 et al June 14, 2002.
|Physical measures, policies, and procedures to protect a covered entity’s electronic information systems and related buildings and equipment, from natural and environmental hazards, and unauthorized intrusion.
|Public Information/Education Committee
|Prepaid Inpatient Health Plans
|Performance Improvement Project/Programs (for Quality Improvement). Also, Provider Incentive Plan
|Per Member Per Month – Revenue to or cost by a provider for each enrolled member each month.
|Point-of-Service – A type of benefit plan in which the insured person can choose to use a non-participating provider at a reduced coverage level and with more out-of-pocket cost. Such POS plans combine both HMC-like systems with indemnity systems. Often known as open-ended HMOs. These plans permit the insured to choose providers outside the plan, yet are designed to encourage the use of network providers. One of the most popular plans with consumers and employers. Represents area of greatest HMO growth.
|Preferred Provider Organization – a variation on the typical contract between an insurer (such as Blue Cross) and an employer providing health care benefits to its employees. In a PPO, the insurer contracts with specific providers and clinics on a fee-for-service basis, but at a discounted rate reflecting the volume of business that PPO members will generate. The PPO may use a single agency as a “gate-keeper” for its system, to do an initial evaluation and then refer the member to a contracted provider of services.
|The prior authorization required by some payers before health benefit payments will be authorized.
|An administrative procedure whereby a health provider submits a treatment plan to a third party before treatment is initiated. The third party usually reviews the treatment plan, monitoring one or more of the following: patient’s eligibility, covered service, amounts payable, application of appropriate deductibles, co-payment factors and maximums. Some programs require predetermination of services. Similar processes: pre-authorization, pre-certification, pre-estimate of cost, pretreatment estimate, and prior authorization.
|Pro-Re-Nata (Latin) which means “as needed”
|Aggregate data in formats that display patterns of health care services over a defined period of time.
|Protected Health Information
|Individually identifiable health information that is: transmitted by electronic media; maintained in electronic media; or transmitted or maintained in any other form or medium. Excludes information in: education records covered by the Family Educational Right and Privacy Act, as amended, 20 U.S.C. 1232g; records described at 20 U.S.C. 1232g(a)(4)(B)(iv); and employment records held by a covered entity in its role as an employer.
|A Practice, clinic, mental health center, hospital, or other organization that is employed by managed health programs to provide treatment services.
|Psychosocial Rehabilitation – a term formerly used to describe Clubhouse Programs. Services that allow the normal care giver (typically the natural family) for a person with a disability, a break from those care-giving responsibilities. Respite care can be for persons with developmental disabilities, for adults with chronic mental illnesses, and for children with severe emotionally disturbance. Respite care may be provided for a few hours or a few days, in the caregivers’ home or in another residential or community setting.
|Means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint or family counseling session and that are separated from the rest of the individual’s medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items; diagnosis, function status, the treatment plan, symptoms, prognosis, and progress to date.
|Public Health Authority
|Means an agency or authority of the United States, a State, a territory, a political subdivision of a State or territory, or an Indian Tribe, or a person or entity acting under a grant of authority from or contract with such public agency, including the employees or agents of such public agency or its contractors or persons or entities to whom it has granted authority, that is responsible for public health matters as part of its official mandate.
|Quality Assessment & Performance Improvement Program
|Quality Improvement Committee/Council/Coordinators
|Quality Improvement Standards for Managed Care
|Quality Oversight Committee
|Quality Oversight Program
|Recipient Rights Complaint
|Required by law
|Means a mandate contained in law that compels an entity to make a use or disclosure of protected health information and that is enforceable in a court of law. Required by law includes, but is not limited to, court orders and court-ordered warrants; subpoenas or summons issued by a court, grand jury, a governmental or tribal inspector general, or an administrative body authorized to require the production of information; a civil or an authorized investigative demand; Medicare conditions of participation with respect to health care provider’s participation in the program; and statutes or regulations that require the production of information, including statues or regulations that require such information if payment is sought under a government program providing public benefits.
|Means a systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge.
|Services that allow normal caregiver a break from care-giving. At GLCMH also represents Crisis Residential through Merediths Home.
|Request for Information – also may be referred to as a Request for Interest or a Request for Ideas. This is a document that outlines a need for a proposed service/program and requests input from Providers or stakeholders in the community. RFIs may be used to determine whether to start a new service/program or if there are existing resources in the community to provide the service/program.
|Request for Proposal – a document that describes an opportunity to acquire funding for a specific purpose, and indicates the requirements for applying for these funds. RFPs may be issued for new programs or services for CMH consumers, as well as for administrative services. The proposals submitted by vendors are reviewed by a Review Committee, based upon set criteria, including quality of services and price.
|Responsible Mental Health Agency – the organization, such as CMH, that holds the contract with the Department of Community Health for provision of mental health services, a residential service provider.
|Recipient Rights Officer or Office
|Retired Senior Volunteer Program
|Social Security Administration
|Security or Security measures
|Encompass all of the administrative, physical, and technical safeguards in an information system.
|Means the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in an information system.
|Supported Employment Program – a form of vocational training in which the consumer is placed in an actual work setting (often part-time) with a local employer, supported by a professional “job coach”. The consumer receives a normal wage for the work performed. This approach is used for adults with developmental disabilities and those with mental illness, as an alternative to more traditional vocational habilitation in a specialized day program. A variation of SEP is Transitional Employment.
|Suicidal Ideation – the forming of suicidal ideas.
|Supported Independent Living Program – community-based services that are individually tailored to assist young adults age 16 and older with acquisition of independent living skills. Services are transitional and will be provided in appropriate community settings, which may include a family home, residential setting or apartment by qualified agencies contracted with a Community Mental Health.
|Specialty Prepaid Health Plans
|Social Security Disability Insurance – Federal Social Security benefits paid to an individual disabled by a condition such as chronic mental illness or developmental disability; these benefits are available when the individual or a parent has paid into the system through Social Security taxes.
|Service Selection Guidelines (DCH Criteria for service)
|Supplemental Security Income – Federal program administered by the Social Security Administration paying benefits to persons with a handicapping disability such as chronic mental illness or developmental disability; the finds come from Federal income tax revenue, not from Social Security taxes paid by or on behalf of the disabled individual.
|Means a rule, condition, or requirement: describing the following information for products, systems, services or practices:
With respect to the privacy of individually identifiable health information.
|Means a constitution, statute, regulation, rule, common law, or other State action having the force and effect of law.
|An arrangement that exists, when an organization being paid under a capitated system, contracts with other providers on a capitated basis, sharing a portion of the original capitated premium.
|Summary Health Information
|Means information, that may be individually identifiable health information, and: that summarizes the claims history, claims expenses, or type of claims experienced by individuals for whom a plan sponsor has provided health benefits under a group health plan; and from which the information described at § 164.514(b)(2)(i) has been deleted, except that the geographic information described in § 164.514(b)(2)(i)(B) need only be aggregated to the level of a five digit zip code.
|Supported Independent Living
|Supports are provided from once weekly to 24 hours a day, depending on individual consumer need, to assist persons to live independently.
|Severely Multiply Impaired – public school terminology for a student with multiple disabilities, e.g. developmental disabilities and vision impairment.
|Telecommunications Device for the Deaf – a separate machine used to adapt a phone for communication by the hearing impaired.
|Means the technology and the policy and procedures for its use that protect electronic protected health information and control access to it.
|Transitional Employment Program – a variation of a Supported Employment Program, with job placements that are planned to be time-limited (usually six months maximum). Through a succession of such placements, the goal is to prepare the consumer for regular competitive employment.
|Traverse House – “Clubhouse” run by NLCMH.
|The Federal Medicaid program legislation.
|Third-Party Administrator – Usually as out-of-house professional firm providing administrative services, such as paying claims, collecting premiums, and carrying out other administrative support services.
|Trading Partner Agreement
|An agreement related to the exchange of information in electronic transactions, whether the agreement is distinct or part of a larger agreement, between each party to the agreement. (For example, a trading partner agreement may specify, among other things, the duties and responsibilities of each party to the agreement in conducting a standard transaction.)
|Traverse Region Assisted Independent Living – Traverse City based service provider for services needed to remain in an Independent living environment.
|Means the transmission of information between two parties to carry out financial or administrative activities related to health care. It includes the following types of information transmissions:
|Means the provision, coordination, or management of health care and related services by one or more health care providers, including the coordination or management of health care by a health care provider with a third party; consultation between health care providers relating to a patient; or the referral of a patient for health care from one health care provider to another.
|The period of treatment between admission and discharge from a modality, e.g., inpatient, residential, partial hospitalization, and outpatient. Many healthcare statistics and profiles use this unit as a base for comparisons.
|Treatment Plan, Individualized
|A written action plan, based on assessment data, that identifies the patient’s clinical needs, the strategy for providing services to meet those needs, treatment goals and objectives, and the criteria for terminating the special interventions.
|Total Quality Management
|Treatment or therapy
|Uniform Bill 1992-Bill form used to submit hospital insurance claims for payment by third parties. Similar to HCFA 1500, but reserved for the inpatient component of health services.
|Utilization Management – a process of review for appropriateness and effectiveness of clinical services rendered to consumers, based on documentation in case records. UM may be “concurrent” (a review of open cases) or “retrospective” (a review of closed cases).
|Utilization Management Committee/Council
|With respect to individually identifiable health information; the sharing, employment, application, utilization, examination, or analysis of such information within an entity that maintains such information.
|Means a person or entity with authorized access.
|Means an electronic computing device, for example, a laptop or desktop computer, or any other device that performs similar functions, and electronic media stored in its immediate environment.
|West Michigan CMH