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| CAPITAL BUDGETING | Funding provided to the Services for the operation of their MTFs based on the number of full-time equivalents (FTE) utilizing the Service's health care system inside and outside catchment areas. |
| CAPITATED BASIS | A fixed per member per month payment or (less often) a percentage of premium paid to a provider, group, organization or facility who assumes the full risk of the cost of contracted services without regard to the type, value, or frequency of services provided. |
| CAPITATION | A payment arrangement on a per-member basis for a given number of patients under a provider's care; a set amount of money received or paid out, based on a prepaid agreement rather than on actual cost of separate episodes of care and services delivered, usually expressed in units of per member per month (PMPM); may be varied by such factors as age, sex, and benefit plan of the enrolled member. |
| CARDED FOR RECORD ONLY (CRO). | Special cases that are not admitted to an inpatient status but require the assignment of a register number |
| CARDIOPULMONARY RESUSCITATION (CPR). | A lifesaving technique that provides artificial circulation and breathing to a person whose heart and lungs have stopped functioning because of a heart attack, shock, drowning, or other cause. |
| CASE MANAGEMENT | Also referred to as Large Case Management. A method of managing the provision of health care to members with catastrophic or high cost medical conditions. The goal is to coordinate the care so as to both improve continuity and quality of care as well as lower costs. This generally is a dedicated function in the utilization management department. |
| CASE MIX | Categories of patients, classified by disease, procedure, method of payment, or other characteristics, in an institution at any given time, usually measured by counting or aggregating groups of patients sharing one or more characteristics |
| CASUALTY. | Any person who is lost to the organization by reason of having been declared dead, wounded, injured, diseased, interned, captured, retained, missing, missing in action, beleaguered, besieged or detained. |
| CASUALTY CATEGORY | A term used to classify a casualty for reporting purpose. (See Joint Pub 4-02 reference (f).) |
| CASUALTY RECEIVING AND TREATMENT SHIP (CRTS). | Amphibious helo/landing craft carriers (LHA, LHD) that convert to casualty receiving ships after troop disembarkment. Provides resuscitative and limited rehabilitative care for casualties resulting from amphibious operations. |
| CASUALTY STATUS | A term used to classify a casualty for reporting purposes. (See Joint Pub 4-02 reference (f).) |
| CASUALY TYPE | A term used to identify a casualty as either a hostile casualty or a nonhostile casualty |
| CATASTROPHIC CASE CUTOFF LIMIT AMOUNT | For budgetary purposes only, each catchment area or predefined geographical area has a specific computed catastrophic case cutoff limit amount that is the specific amount that an individual CHAMPUS beneficiary patient case and/or episode must exceed to be considered catastrophic. A case limit amount is computed annually for each MTF or geographical area by utilizing past historical data and choosing the limit amount where historical "catastrophic" totals are at a predetermined percentage of the area's total annual budget. The case limit amount is then applied to individual patient cases in that geographical area during the upcoming fiscal year to determine whether or not they have exceeded the catastrophic case limit and are thus considered to be catastrophic. |
| CATASTROPHIC CASE WITHHOLD AMOUNT | For budgetary purposes only, once a catastrophic case limit amount for an MTF or geographical area has been computed for an upcoming fiscal year, the limit is applied back to the prior historical period's data to see what the total catastrophic amount would have been for the geographical area using that specific patient case limit cutoff amount using the previous beneficiary cases for the period. The total of all catastrophic amounts for the geographic area for the previous period is then defined as the catastrophic case withhold amount. For those Tri-Service areas using this catastrophic resource management tool, the catastrophic withhold amount is then withheld from the catchment area or geographical area when given their CHAMPUS operating funds at the beginning of the fiscal year. Subsequently, after each quarter of the current fiscal year, the catastrophic case limit, applied to the actual geographical area, is reimbursed for the total of those catastrophic payments out of their withheld catastrophic budgetary fund. |
| For budgetary purposes only, once a catastrophic case limit amount for an MTF or geographical area has been computed for an upcoming fiscal year, the limit is applied back to the prior historical period's data to see what the total catastrophic amount would have been for the geographical area using that specific patient case limit cutoff amount using the previous beneficiary cases for the period. The total of all catastrophic amounts for the geographic area for the previous period is then defined as the catastrophic case withhold amount. For those Tri-Service areas using this catastrophic resource management tool, the catastrophic withhold amount is then withheld from the catchment area or geographical area when given their CHAMPUS operating funds at the beginning of the fiscal year. Subsequently, after each quarter of the current fiscal year, the catastrophic case limit, applied to the actual geographical area, is reimbursed for the total of those catastrophic payments out of their withheld catastrophic budgetary fund. | The potential loss due to the actual cost of claims exceeding the AAPCC "credit" or revenue provided by HCFA for enrolled patients for which the MTF is "at risk"; the cost of claims may include the MTF's actual cost of providing care, plus the cost of any "downtown" or network care from the TRICARE Managed Care Support Contractor |
| CATCHMENT AREA | Defined geographic area served by a hospital, clinic, or dental clinic and delineated on the basis of such factors as population distribution, natural geographic boundaries, and transportation accessibility. For the DoD Components, those geographic areas are determined by the Assistant Secretary of Defense (Health Affairs) and are defined by a set of 5-digit zip codes, usually within an approximate 40-mile radius of military inpatient treatment facilities |
| CEILING | A numerical limitation imposed by the Office of the Secretary of Defense (OSD) on the number of military and civilian manpower spaces authorized to each Service. |
| CENSUS, AVERAGE DAILY | Average number of inpatients, excluding newborns, receiving care each day during a reported period |
| CENSUS BASSINET DAYS | The total number of beds occupied at the census taking hour for a specified period. |
| CENSUS, INPATIENT | Number of inpatients in a hospital at a given time. That time is the census taking hour and is usually midnight |
| CENSUS, LIVE BIRTH BED + BASSINET DAYS (CLBBD). | The total number of live birth beds + bassinets occupied at the census taking hour for a specified period. |
| CENSUS BED DAYS PER DISPOSITION (CBDD). | The average census bed days of all or a class of inpatients over a given time period, calculated by dividing the sum of census bed days by the number of dispositions in that given time frame. This computation includes patients still occupying beds. This will be the computation used by the Medical Expense and Performance Reporting System (MEPRS). The CBDD replaces what was previously referred to as ALOS in MEPRS. (Formula: CBDD = Total OBDs reported for a period/Total dispositions reported for the period). |
| CENTRAL PROCESSING AND DISTRIBUTION (CPD) SYSTEM | Medical logistics AIS that provides supply distribution on non-pharmaceuticals to ward and clinics. Processes include inventory management and inventory financial accounting. |
| CERTIFICATE OF NEED (CON). | The requirement that a health care organization obtain permission from an oversight agency before making changes. Generally applies only to facilities or facility-based services |
| CERTIFICATION | The process by which a governmental or non-governmental agency or association evaluates and recognizes a person who meets predetermined standards; sometimes used with reference to materials or services. "Certification" is usually applied to individuals and "accreditation" to institutions. |
| CERTIFIED NURSE MIDWIFE (CNM). | An individual educated in the two disciplines of nursing and midwifery who possesses evidence of certification according to the requirements of the American College of Nurse-Midwives (ACNM). |
| CHAMPUS DETAIL INFORMATION SYSTEM (CDIS). | Online data views, at a detail level, of the OCHAMPUS beneficiary and provider CHAMPUS HCSR records. |
| CHAMPUS MEDICAL INFORMATION SYSTEM (CMIS). | Online data views, at a summary level, of the OCHAMPUS beneficiary and provider CHAMPUS HCSR record data. |
| CHARGE | Dollar amount charged by a hospital, physician, or other health care provider for a unit of service, such as a stay in an inpatient unit or a specific medical or dental procedure |
| CHIEF EXECUTIVE OFFICER | A job-descriptive term used to identify the individual appointed by the governing body to act on its behalf in the overall management of the hospital. |
| CHIEF OF SERVICE | Member of a hospital staff who is elected or appointed to serve as the medical and/or administrative head of a clinical service. |
| CHRONIC DISEASE | Disease that develops slowing and persisting for a long period of time usually for the remainder of the lifetime of the patient. |
| CHURNING | The practice of a provider seeing a patient more often than is medically necessary, primarily to increase revenue through an increased number of services. Churning may also apply to any performance-based reimbursement system where there is a heavy emphasis on productivity (in other words, rewarding a provider for seeing a high volume of patients whether through fee-for-service or through an appraisal system that pays a bonus for productivity). |
| CIVILIAN EXTERNAL PEER REVIEW PROGRAM | The program whereby military health care services are assessed by civilian experts (professional peers) with collaboration with pertinent military consultants. The program is performed for the Department of Defense under contract. |
| CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED SERVICES (CHAMPUS). | An indemnity-like program called TRICARE standard that is available as an option under DoD's TRICARE program. There are deductibles and cost shares for care delivered by civilian health care providers to active duty family members, retirees and their family members, certain survivors of deceased members and certain former spouses of members of the seven Uniformed Services of the U.S. |
| CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE DEPARTMENT OF VETERANS AFFAIRS (CHAMPVA). | Program administered by the Department of Defense for the Department of Veterans Affairs that cost-shares for care delivered by civilian health providers to family members of totally disabled veterans that are eligible for retirement pay from a Uniformed Service of the United States. |
| CLAIM | Any request for payment for services rendered related to care and treatment of a disease or injury that is received from a beneficiary, a beneficiary's representative, or an in-system or out-of-system provider by a CHAMPUS FI/Contractor on any CHAMPUS-approved claim form or approved electronic media. Types of claims and/or data records include Institutional, Inpatient Professional Services, Outpatient Professional Services (Ambulatory), Drug, Dental, and Program for the Handicapped. |
| CLAIM TYPE AND/OR RECORD TYPE | Type of data submitted on a CHAMPUS claim, dependent on the type of services that were provided. CHAMPUS claim and/or record types are Institutional, Inpatient Professional Services, Outpatient Professional Services (Ambulatory), Drug, Dental, and Program for the Handicapped. |
| CLINIC | A health treatment facility primarily intended and appropriately staffed and equipped to provide emergency treatment and ambulatory services. A clinic is also intended to perform certain non-therapeutic activities related to the health of the personnel served, such as physical examinations, immunizations, medical administration, preventive medicine services, and health promotion activities to support a primary military mission. In some instances, a clinic may also routinely provide therapeutic services to hospitalized patients to achieve rehabilitation goals; e.g., occupational therapy and physical therapy. A clinic may be equipped with beds for observation of patients awaiting transfer to a hospital, and for the care of cases that cannot be cared for on an outpatient status, but that do not require hospitalization. Such beds shall not be considered in calculating occupied-bed days be MTFs. |
| CLINIC SERVICE | A functional division of a department of a Military Treatment Facility identified by a three-digit MEPRS code. |
| CLINICAL PRACTICE GUIDELINES | Systematically developed statements to assist provider and patient decisions about appropriate health care for specific clinical conditions. |
| CLINICAL PRIVILEGES | Permission to provide medical, dental, and other patient care services in the granting institution, within defined limits, based on the individual's education, professional license, experience, competence, ability, health, and judgment. |
| CLINICAL SUPPORT STAFF | Personnel who are required to be licensed but are not included in the definition of health care Practitioners. This category includes dental hygienists and non-privileged nurses. |
| CLINICIAN | A "clinician" is defined as a physician or dentist practitioner normally having admitting privileges and primary responsibility for care of inpatients. Interns and resident physicians and dentists are considered clinicians only for purposes of meeting the requirements of the manual and NOT for the purposes of JCAHO accreditation, credentialing, etc. A physician or dentist assigned to and/or working at a clinic with no inpatient capability will still be considered a clinician on the premise that if assigned to a hospital, he or she would have admitting privileges. For manpower purposes, all physicians and dentists are considered clinicians. For expense purposes, clinician salary expenses are processed in a manner that will align inpatient expenses to permit comparison between civilian facility and military facility inpatient care costs. Salary expenses to be accounted for separately will be for those clinicians whose services are normally provided in the civilian sector by clinicians not employed by the hospital and who bill the patient directly. |
| CLINICIAN, MEPRS | A physician or dentist practitioner normally having admitting privileges and primary responsibility for care of inpatients. Intern and resident physicians and dentists are considered to be clinicians as far as the Medical Expense and Performance Reporting System (MEPRS) reporting categories only for the purposes of meeting the requirements for MEPRS. |
| CLOSED PANEL | A managed care plan that contracts with physicians on an exclusive basis for services and does not allow those physicians to see patients for another managed care organization. Examples include staff and group model HMOs. Could apply to a large private medical group that contracts with an HMO. |
| CLOSE OBSERVATION ROOM (COR). | A room on an inpatient nursing unit or ward, located near the nursing station, specifically designated a COR in the facility plan, for patients who require a higher level of nursing care than is typical for the nursing unit or ward but a lower level of care than that provided in a Special Care Unit. |
| COINSURANCE. | A provision in a member's coverage that limits the amount of coverage by the plan to a certain percentage, commonly 80%. Any additional costs are paid by the member out of pocket. |
| COMBATANT COMMAND | One of the Unified Commands established by the President |
| COMBAT SERVICE SUPPORT | The essential capabilities, functions, activities and tasks necessary to sustain all elements of operating forces in theater at all levels of war. (See Joint Pub 4-02 reference (f).) |
| COMMAND AND CONTROL | The exercise of authority and direction by a properly designated commander over assigned forces in the accomplishment of the mission. (See reference (f).) |
| COMMUNICATIONS ZONE | Rear part of theater of operations (behind but contiguous to the combat zone) that contains the lines of communication, establishments for supply and evacuation and other agencies required for immediate support and maintenance of the field forces. |
| COMORBIDITY | A preexisting condition on admission that will, because of its presence with a specific diagnosis, prolong the length of stay by at least one day in 75% of the patients |
| COMPETENCE | The ability to make an informed choice |
| COMPLETE PHYSICAL EXAMINATION, COUNT OF | A total record of the number of persons given complete physical examinations (except flight physical examinations, which are counted separately). Annual, enlistment, reenlistment, appointment, and promotion are examples of complete physical examinations. Visits made to various clinics incident to the physical examination are counted as visits in addition to this selective reporting. |
| COMPLICATION | A condition that arises after the beginning of hospital observation and treatment and alters the course of the patient's illness or the medical care required. |
| COMPOSITE HEALTH CARE SYSTEM (CHCS). | Medical AIS that provides patient facility data management and communications capabilities. Specific areas supported include MTF health care (administration and care delivery), patient care process (integrates support--data collections and one-time entry at source), ad hoc reporting, patient registration, admission, disposition, and transfer, inpatient activity documentation, outpatient administrative data, appointment scheduling and coordination (clinics, providers, nurses, and patients), laboratory orders (verifies and processes), drug and lab test interaction, quality control and test reports, radiology orders (verifies and processes), radiology test result identification, medication order processing (inpatient and outpatient), medicine inventory, inpatient diet orders, patient nutritional status data, clinical dietetics administration, nursing, order-entry, eligibility verification, provider registration, and the Managed Care Program. |
| COMPOSITE LAB VALUE (CLV). | A weighted time factor for dental laboratory procedures |
| COMPOSITE TIME VALUE (CTV). | A weighted time factor for clinical dental procedures |
| COMPREHENSIVE HEALTHCARE CLINIC (CHCC). | A facility planned, designed and constructed to provide comprehensive ambulatory care services, to include ambulatory surgery, and limited holding bed capability |
| COMPUTER ASSISTED PROCESSING OF CARDIOGRAMS I (CAPOC I). | Medical AIS that provides computer-assisted interpretation of ECG data. Specific capabilities include: ECG reading, analysis, and transmission site locator, hard copy report generator, machine analysis at central site, physician review and confirmation, patient records updates, records storage and retrieval, and patient demographic data collection. |
| COMPUTER ASSISTED PROCESSING OF CARDIOGRAMS II (CAPOC II). | Same as CAPOC I. Medical AIS that will provide MTFs and clinics an ECG database and reporting capability similar to CAPOC I, but augmented by an interpretation functionality |
| COMPUTED AXIAL TOMOGRAPHY (CAT). | An x-ray imaging device that produces highly definitive cross sectional images of the body by computer manipulation. |
| COMPUTER BASED PATIENT RECORD | Contains information about an individual's longitudinal health status and health care. Appropriate portions are easily accessible to authorized users when and where needed. The Computer based patient record integrated computer systems facilitate the worldwide delivery of health care, assist individuals and clinicians in making health care decisions, and support leaders in making operational and resource allocation decisions. |
| CONSTRUCTION | The erection, installation, or assembly of a new facility; the addition, expansion, extension, alteration, conversion, or replacement of an existing facility; or the relocation of a facility from one activity or site to another activity or site. It includes equipment installed in (Real Property Installed Equipment) and made a part of such facilities, related site preparation, excavation, filling and landscaping, or other land improvements. |
| CONSULTANT. | An expert in a specific medical, dental, or other health services field who provides specialized professional advice or services upon request |
| CONSULTATION | A deliberation with a specialist concerning the diagnosis or treatment of a patient. To qualify as a consultation (for statistical measure) a written report to the requesting health care professional is required |
| CONTINENTAL UNITED STATES (CONUS). | United States territory, including the adjacent territorial waters located within the North American continent between Canada and Mexico. Alaska and Hawaii are not part of the CONUS |
| CONTINUED HEALTH CARE BENEFIT PROGRAM (CHCBP). | The CHCBP, provides temporary continued CHAMPUS benefits for certain former CHAMPUS beneficiaries. Coverage is purchased on a premium basis. |
| CONTINUING EDUCATION | Officers, equivalent civilians, and selected enlisted personnel working in a medical specialty, have a responsibility to maintain their knowledge within their professional discipline. Often this responsibility has been codified into a professional requirement either by nationally recognized certifying associations and/or boards, State licensure bodies, or Military medical departments. This type of training requirement has become known as continuing education. The salary expenses of military and civilian personnel meeting these requirements shall be included. Education beyond initial professional preparation that is relevant to the type of patient care delivered in the organization, and/or provides current knowledge relevant to the individual's field of practice, and/or health care delivery in general. |
| CONTINUUM OF CARE | A way of looking at the level and type of care provided to individuals from the most acute and intensive to the least acute and least intensive. The concept of the continuum is important because integrated health networks of the future will be expected to provide the entire range of services contained on the continuum. |
| CONTRACT COMPLETION DATE (CCD). | The date when a contractor has fulfilled all contract requirements and the Government assumes control of the contractor's product. |
| CONTRACTOR (TRICARE/GOVERNMENT CONTRACTOR). | A government-selected civilian health care organization designated on a region by region and/or area by area bid-price contractual basis. Each TRICARE Contractor supplements all Tri-Service military direct care for beneficiaries in the applicable geographical area. The Contractor provides managed care support to TRICARE Prime enrollees and organizes the Preferred Provider Network (PPN) for beneficiaries in TRICARE Prime and those utilizing TRICARE Extra. |
| CONVALESCENT CARE | Care rendered to patients who are ambulatory. Complexity of care requires limited therapeutic intervention and administration of oral medications performed by the patient. Patients are in the final stages of recovery and could be returned to limited duty. Emphasis is on physical reconditioning. |
| CONVALESCENT LEAVE | An authorized leave status, not chargeable to the individual, granted to active duty Uniformed Service Members while under medical or dental care that is part of the care and treatment prescribed for a member's recuperation or convalescence. Convalescent leave days are not counted as occupied bed days but are counted as sick days, when the convalescent leave occurs before the disposition of the patient. Convalescent leave occurring after disposition of the patient while en route to a new command, or convalescent leave granted by a line commander after patient discharge from the hospital is not counted as occupied bed days or sick days. |
| COOPERATIVE CARE | Those medical inpatient and/or outpatient services and supplies provided to non-active duty beneficiaries under specified circumstances and by a civilian source. During cooperative care, CHAMPUS shares in the cost even though the patient remains under the primary control of the Military Treatment Facility. |
| COPAYMENT | That portion of a claim or medical expense that an individual must pay out of pocket. Usually a fixed amount, such as $5 in many HMOs |
| CORONARY CARE UNIT (CCU). | A medical care unit in which there is appropriate equipment and a concentration of physicians, nurses, and others who have special skills and experience to provide optimal medical care for critically ill coronary or cardiac patients. |
| CORPORATE EXECUTIVE INFORMATION SYSTEM (CEIS). | The CEIS is a target Tri-Service system for integrating executive information support requirements across the MHS. |
| COST ASSIGNMENT | MEPRS uses a standard cost assignment methodology to distribute expense from MEPRS cost pool accounts, MEPRS ancillary accounts, and MEPRS support service accounts to other MEPRS accounts (i.e., inpatient, outpatient, dental special programs and readiness accounts). "Cost distribution" is often used as a synonym for cost assignment. |
| COST-EFFECTIVE | A way of relating the cost of care to the achievement of a desired health outcome. The most cost-effective method is the one that achieves the health outcome at the least cost. |
| COST POOL | MEPRS provides for the use of these accounts to collect expenses that cannot be readily identified with a particular MEPRS workcenter and/or account. These expenses are charged to MEPRS cost pool accounts and subsequently assigned in MEPRS to appropriate MEPRS final workcenter accounts (i.e., inpatient, outpatient, dental, special programs, and readiness MEPRS accounts). |
| COST SHIFTING | The practice of charging certain groups of patients higher rates to offset lower rates negotiated with, or mandated by, other payers. |
| COVERED SERVICE | This term refers to all of the medical services the enrollee may receive at no additional charge, or with an incidental copayment under the terms of the prepaid health care contract |
| CREDENTIALING | The most common use of the term refers to obtaining and reviewing the documentation of professional providers. Such documentation includes licensure, certifications, insurance, evidence of malpractice insurance, malpractice history, and so forth. Generally includes both reviewing information provided by the provider as well as verification that the information is correct and complete. A much less frequent use of the term applies to closed panels and medical groups and refers to obtaining hospital privileges and other privileges to practice medicine. |
| CENTRALIZED CREDENTIALS AND QUALITY ASSURANCE SYSTEM (CCQAS). | CCQAS is a window database for managing medical readiness training certification, credentials, and risk management information of health care providers. |
| CREDENTIALS | Documents that constitute evidence of qualifying education, training, licensure, certification, experience and expertise of health care providers. Professional qualifications including professional degree, post-graduate training and education, board certification, and licensure, etc. |
| CREDENTIALS PROCESS AND REVIEW | The application and screening process whereby health care providers have their credentials evaluated before being granted clinical privileges or assigned patient care responsibility. |
| CURRENT PROCEDURAL TERMINOLOGY 4th EDITION (CPT-4). | A set of five-digit codes that apply to medical services delivered. Frequently used for billing by professionals. |
| CURRENT PROCEDURAL TERMINOLOGY 4th EDITION (CPT-4) MODIFIER | A modifier to a CPT-4 coded procedure provides a means by which a reporting professional services provider can indicate that a rendered service or procedure has been altered by some specific circumstance but not changed in its definition or code. For instance, this modifier may show that a procedure was performed by more than one physician and/or at more than one location, whether a service or procedure was performed more than once, only partially, with an adjunctive service, or as a bilateral procedure. |
| CUSTODIAL CARE | Care rendered to a patient who is mentally or physically disabled. Such disability is expected to continue and be prolonged. The patient requires a protected, monitored or controlled environment and requires assistance to support the essentials of daily living. The patient is not under active and specific medical, surgical or psychiatric treatment that will reduce the disability enough so that the patient can function outside the protected, monitored or controlled environment of the institutional setting. Custodial care occurs when a patient is medically stabilized and when all reasonable therapeutic efforts have been completed but, despite maximum reasonable rehabilitation, the patient still requires the protected, monitored or controlled environment of an institutional setting. A custodial care determination is not prevented by the fact that a patient is under the care of a supervising or attending physician and that services are being ordered and prescribed to support and generally maintain the patient's condition, or to provide for the patient's comfort, or to assure the manageability of the patient. Further, this determination is not precluded because an RN, LPN, or LVN is providing the required and prescribed services and supplies. |
