Cost and Utilization Report Glossary
Administrative services only (ASO) plan:
An arrangement wherein a third party handles the administration of a self-funded benefit program for a fee. See also self-funded benefit program.
See prices paid.
See prices paid.
Ambulatory payment classification (APC):
A system of grouping hospital outpatient services with similar clinical characteristics, costs, and procedure codes. These groupings were developed by the
Centers for Medicare & Medicaid Services (CMS).
Ambulatory payment classification (APC) weight:
Prospectively-determined relative weight assigned to each APC grouping by CMS, published in the Hospital Outpatient Prospective Payment System Final Rule
each calendar year.
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.
Centers for Medicare & Medicaid (CMS):
A federal agency within the U.S. Department of Health and Human services and charged with administering public health care programs, including the Medicare
and Medicaid public insurance programs and the U.S. Health Insurance Marketplace.
Geographic areas determined by the United States Census. In HCCI reporting, census region refers to the division of the 50 United States and the District
of Columbia into four geographic areas: Midwest, Northeast, South, and West.
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.
Consumer-driven health plan (CDHP):
Health plans that have a high deductible and include either a health reimbursement account (HRA) or a health savings account (HSA).
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.
Current procedural terminology (CPT) code:
Unique identifiers developed by the American Medical Association (AMA) to classify medical services and procedures furnished by physicians and other health
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.
Diagnosis-related groups (DRG):
A system of classification of inpatient hospital services based on principal diagnosis, secondary diagnosis, surgical procedures, age, gender, and presence
Diagnosis-related groups (DRG) weights:
A metric that captures the average resources used to treat patients within a DRG in a specific fiscal year, assigned by CMS. The metric is often used as a
mechanism to reimburse hospitals and selected health care providers for services rendered and is typically based on the average cost of all patients within
Emergency room (ER):
A section of the hospital where emergency treatment and diagnosis is provided.
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.
Fully-insured benefit program:
An employee health insurance plan that is purchased by an employer through a health plan. The health plan pays both claims and administrative costs and
assumes the insurance risk.
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.
Healthcare common procedure coding system (HCPCS):
A means of classifying medical items or services in claims and patient discharge data.
Special care provided by a program or facility for the terminally ill and their families.
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.
Inpatient service categories:
A classification of inpatient admissions based on the type of service provided during the hospital stay.
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.
Length of stay (LOS):
The number of days a patient stays overnight in a hospital or medical facility and usually counted by the presence of the patient in the facility at
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.
Major diagnostic category (MDC):
A coding scheme composed of 27 diagnosis categories based on major organ systems that are aggregations of Diagnostic-Related Group (DRG) codes
Children younger than 1 year of age.
A room in a hospital facility where the status and treatment of a patient is monitored and distinct from a hospital admission.
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.
Place of service (POS) code:
A classification scheme to capture the type of health service setting that provided a medical 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.
Primary care provider (PCP):
Health professional who offers non-specialist care to patients and usually provides ongoing care for health maintenance. HCCI classified the following
types of physicians as PCP providers: family practice, geriatric medicine, internal medicine, pediatrics, and preventive medicine.
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.
A monetary payment to a provider for any type of claim.
Relative value units (RVU):
A classification scheme based on the skill, effort, and time required by a health care professional for a given medical procedure or service in comparison
to other medical procedures and services. The scheme is based on the relative level of time and intensity associated with furnishing the service as set by
CMS with commercial adjustments.
A code assigned to a medical service or treatment for receiving proper payment, typically in a hospital setting.
Self-funded benefit program:
A health insurance plan in which the employer pays the insurance claims. See also administrative services only plan.
Skilled nursing facility (SNF):
A facility that provides skilled nursing and rehabilitation services but with less care and intensity than would be provided in a hospital. Services
provided at a skilled nursing facility include both medical and custodial services. Stays that include only custodial care (such as assistance with
bathing, feeding, and dressing) are not skilled nursing care.
A health care professional who provides care for patients requiring a specific category of medical services and who has intensive training in that category
A classification of a drug or a medical device based on function and use.
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.
Centers for Medicare and Medicaid Services. Payment System Fact Sheet Series: Hospital Outpatient Prospective Payment System [Internet]. Baltimore
(MD): CMS; 2012 Feb [cited 2012 May 17]. Available from
U.S. Department of Commerce Economics and Statistics Administration, US Census Bureau. Census Regions and Divisions of the United States
[Internet]. Available from: http://www.census.gov/geo/maps-data/maps/pdfs/reference/us_regdiv.pdf.
CPT codes and descriptions only are copyright of the American Medical Association. All Rights Reserved.