HCCI Research Glossary
See prices paid.
See prices paid.
A drug or medical device that is prescribed by a health care provider and marketed under a trade name approved by the U.S. Food and Drug administration
(USFDA). See also generic prescription.
The dollar amount a provider charged/asked for medical services rendered; such charges can differ from the prices paid to that provider for medical
services rendered. See also prices paid.
A portion of covered health care costs borne by an insured. After the insured meets a deductible requirement, insurers often apply coinsurance according to
a fixed percentage of the prices paid.
A cost-sharing arrangement in which the insured pays a specified charge for a specified service. Typical co-payments are fixed flat amounts for physician
office visits, prescriptions, or hospital services.
The amount that the insured must pay out of pocket to providers before the health plan pays any reimbursement to the insured. For example, an insured with
a $1,000 deductible would pay the first $1,000 of service costs in the given year. After the deductible is satisfied, the beneficiary and the health plan
jointly pay further expenses according to the insurance contract.
Employer-sponsored insurance (ESI):
A health insurance policy provided by an employer to its employees and their families. The employer and employee usually jointly pay premiums. See also
fully-insured benefit program and self-funded benefit program.
A request for payment from a facility that provided a medical service, limited to the cost of using a room and associated services within the facility; it
does not include any procedures performed by health professionals on the insured. Charges for physician services are rendered separately as “professional
The number of days’ supply for one filled drug or medical device prescription. See also prescription.
One prescription drug claim for a drug or medical device regardless of number of days filled; each refill equals one script. See also prescription.
A drug or medical device that is prescribed by a health care provider, is not marketed under a trade name, but is approved by the U.S. Food and Drug
administration (USFDA). Generics have the same quality and chemical composition as a brand prescription and enter the market once exclusions on the brand
prescription expire. See also brand prescription.
An admission to a hospital that includes an overnight stay. See also length of stay.
A medical setting, such as hospitals, hospices, and skilled nursing facilities, where patients are kept overnight for treatment.
An individual covered by health insurance. See also beneficiary and member.
The number of months an insured has health insurance in a given year.
A measure of the complexity of a service, including the length of time, the severity of the illness addressed, and the amount of resources required for
treatment. It is a component of price per service.
The amount paid by insurers and beneficiaries to a provider for a health care provision, modified for the resource mix (intensity) of the services
provided. It is a component of price per service.
An individual covered by a specific health insurance plan; could be the primary coverage holder or a dependent. See also beneficiary and insured.
The number of months for which an individual is covered by a specific health insurance plan. An insured covered for 12 member months in a calendar year
would be covered for 1 year of insurance. See also insured months.
A portion of allowed costs for medical services and treatment paid by the patient, including copays, coinsurance, and deductibles. See also prices paid.
A facility or unit in a facility that provides medical services not requiring an overnight stay or hospitalization.
The party who is financially responsible for the amount of the claim covered by the contract.
Per capita expenditure:
The sum of prices paid divided by the insured population; also calculated by multiplying total utilization and price per service.
An order from a health care professional and given to a patient to obtain drugs or medical devices that cannot be purchased over the counter.
Price per service:
A combination of intensity-adjusted price and intensity; calculated by multiplying the components.
The amount paid to a provider for a medical service or supply after provider discounts. It is also defined as negotiated rates paid by a health plan to a
provider for a medical service or supply that qualifies as a covered expense. This amount is the shared responsibility of the health plan and the insured
and excludes amounts for non-covered services. It includes the payment by the insurer and the out-of-pocket payments of the insured.
Professional procedure claim:
A claim filed by a health care professional for medical services rendered. It includes claims for professional procedures as opposed to facility claims,
including office visits, lab tests, and immunizations.
See intensity-adjusted price.
The amount of medical service consumed by patients within a given time period; used in aggregate in the report to be the average rate of use per insured
person or multiplied by 1,000 as the rate of use per 1,000 individuals.