| A | B |
|---|
| Primary Care Physician | gatekeeper |
| referral | authorization from PCP to be treated by specialist |
| staff model | multispecialty group practice where healthcare services are provided within the building owned by HMO |
| group model | HMO contracts with independent, multispecialty physician group who provide all healthcare services to its members |
| capitation | fixed fee for every patient enrolled in an HMO plan |
| network model | allows multiple provider arrangements, including staff, group, and IPA structures |
| mixed model | offers the widest variety of choices and broadest geographic coverage to members |
| direct contract model | similar to IPA except conntracts directly with individual physicians |
| Individual Practice Association | service provided by outpatient networks composed od individual healthcare providers |
| Point-of-Service | hybrid type of managed care also known as "open-ended HMO" |
| Provider-Sponsored Organization | falls under the Medicare Part C Medicare Advantage Plans |
| National Committee on Quality Assurance | nonprofit organization, accredits healthcare plans on quality of care and member satisfaction rates |
| The Joint Commission | not-for-profit organization that is considered the predominant standards-setting and accrediting body in health |
| Utilization Review Accreditation Commission | promotes healthcare quality by accrediting types of healthcare organizations depending on functions they carry out |
| utilization review | system designed to determine medical necessity and appropriateness of medical services, procedures, and hospital admissions |
| grievance | written complaint submitted by individual covered by insurance plan |
| preauthorizaation | prior approval of specific procedures or treatments for a patient |
| precertification | a formal assessment of medical necessity, efficiency, or appropriateness of medical provider's treatment plan |
| predetermination | provider notifies insurance company of the recommended treatment before it begins |
| consultation | PCP sends patient to another healthcare providers to give his expert opinion regarding patient's condition |
