Glossary of Terms

Glossary of Terms

Glossary of Healthcare Industry and Medical Practice Management Terms

Each section below contains a glossary of terms related to the specific subject. We add new topics on a regular basis, so check back or contact us if you’d like us to cover a specific area or if you have questions about a specific topic or term.

CLIA Glossary

The following terms are commonly used in CLIA Compliance. The inclusion of any term, however, does not constitute an endorsement or recommendation by DoctorsManagement or any of its subsidiaries or employees.

1.)   CLIA means the Clinical Laboratory Improvement Amendments of 1988.

2.)   Certificate of Waiver (COW) allows a facility to do only waived tests.

3.)   PPMP Certificate allows qualified providers to do waived testing and certain microscopic examinations during the patients’ visit.

4.)   Certificate of Registration or Registration Certificate means a certificate issued to a laboratory that enables the entity to conduct moderate or high complexity laboratory testing or both until the entity is determined to be in compliance through a survey by the Centers for Medicare and Medicaid Services (CMS) or its agent; or in accordance with Sec. 493.57 to an entity that is accredited by an approved accreditation organization.

5.)   HHS means the Department of Health and Human Services, or its designee.

6.)   Kit means all components of a test that are packaged together.

7.) Laboratory means a facility for the examination of materials derived from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings. These examinations also include procedures to determine, measure, or otherwise describe the presence of various substance or organisms in the body. Facilities only collecting or preparing specimens (or both) or only serving as a mailing service and not performing testing are not considered laboratories.

8.)   MedWatch is an FDA service for health care facilities to voluntarily report a serious adverse event or product problem that the user suspects is associated with a drug or medical device used, prescribed, or dispensed.


Phone: 1-800-FDA-1088

9.)   A Pipet/Pipette is a narrow, usually calibrated glass or plastic tube into which small amounts of liquid are suctioned for transfer or measurement.

10.) Plasma is the usually clear, yellowish fluid portion of blood, lymph, or intramuscular fluid in which cells are suspended. It is the fluid produced when a blood specimen is collected in a vacuum tube with anticoagulant.

11.) Serum is the usually clear yellowish fluid obtained upon separating whole blood into its solid and liquid components after it has been allowed to clot. Also called blood serum.

12.)   A Reagent is a substance or material or ingredient used in a lab test to detect, measure, examine, or produce other substances.

13.) Controls are materials with known values of the substance measured that help the laboratory achieve accurate and reliable testing by checking if the test system is working. Controls, also known as quality control material, are external or internal. External controls are usually a liquid and are processed or tested in the same manner is a patient specimen. Internal or procedural controls are indicators that the test procedure was performed in the proper order.

14.) Quality Control (QC) procedures help to ensure the excellence of the patient testing. If the QC results are not within the prescribed range or the expected pattern, then the laboratory cannot be sure that the patient’s test results are accurate and reliable. See Controls above.

15.) Quality Assurance (QA) is the laboratory’s self-examination of the specimen collection, testing, and test reporting processes. What does the laboratory do to assure accurate results?

Ten recommended QA questions to ask are:

  • Are the patients and specimens properly identified?
  • Are the patients’ charts up-to-date with the proper patient test information?
  • Is the quality control performed and documented?
  • Did the laboratory get the right answers for the quality control?
  • Do the waived test results correlate with the patient’s history or symptoms?
  • Are there any complaints about the laboratory testing?
  • Are the testing personnel trained prior to performing laboratory testing?
  • Are there periodic discussions about laboratory concerns?

16.) Screening Tests are initial tests to determine if a disease or medical condition exists.

17.) Diagnostic Tests are tests to identify a disease or medical condition that exists in a patient.

18.) Monitoring Tests are tests that are done once a patient is diagnosed with a disease or medical condition. These tests help the clinician keep track of the patient’s specific medical condition or response to a treatment on a periodic basis.

19.) Routine Order of Draw (when the laboratory collects more than one tube of blood at a time on a patient):

  • Blood culture tube
  • Non-additive serum tube
  • Citrate tube
  • SST (serum separator tube), plastic serum tube
  • Heparin tube
  • EDTA tube
  • Glycolytic inhibitor tube

Please consult with the reference laboratory for specific specimen collection requirements.

20.) Package Insert is the instructions included by the manufacturer in the kit or test package. Read these carefully each time a new kit is opened to check for changes in procedures or quality control. Retain the current package insert for reference. The language used to convey the instructions is important. Words like “always”, “shall”, “must”, and “required” mean the instruction is regulatory and must be performed. “Should” or “recommend” mean the action is not regulatory, but it is good laboratory practice to perform those actions.

HIPAA Glossary

The following terms are commonly used in HIPAA Compliance. The inclusion of any term, however, does not constitute an endorsement or recommendation by DoctorsManagement or any of its subsidiaries or employees.

Administrative Safeguards: Policies and procedures to maintain security of ePHI (electronic protected health information).

Amendment: Information added to a record in order to correct an omission or error.

ARRA: American Recovery and Reinvestment Act, a.k.a. “Stimulus package.” Includes HITECH.

Authentication: Means of establishing or verifying the identity of an individual

Authorization: Special permission to use protected health information for other than treatment, payment or health operations. It must include certain elements as required by HIPAA.

Bio-identifiers: Biological features or data used to establish or verify the identity of an individual, including fingerprints, full face photos, and iris patterns.

Breach: Impermissible and accidental access, acquisition, use, or disclosure of unsecured ePHI that poses a significant risk of financial, reputational, or other harm to the individual who is the subject of the information. Excludes internal incidents, de-identified information, and information that has been made impossible for the unintended individual to maintain or interpret it.

Breach Notification: Process of informing affected individuals, the Secretary of HHS (Health and Human Services), and the media (if applicable) of unauthorized use or disclosure of unsecured PHI.

Business Associate: Entity or individual that is not a part of the workforce and is not a covered entity, but creates, receives, maintains, or transmits PHI on behalf of a covered entity. Examples: billing company, EHR and PMS vendors, ePrescribing gateways, health care clearing houses, IT support.

Business Associate Agreement: Document initiated by covered entities to ensure that business associates maintain required safeguards to protect health information as required by HIPAA.

Confidentiality: Property of not allowing unauthorized persons to have access to information.

Covered Entity: Health plan, health care clearinghouse, or a health care provider who transmits any health information in electronic form.

Court Order: An official proclamation by a judge (or panel of judges) that defines the legal relationships between the parties to a hearing, a trial, an appeal or other court proceedings. Such ruling requires or authorizes the carrying out of certain steps by one or more parties to a case. A court order must be signed by a judge. Some jurisdiction may require it to be notarized. The content and provisions of a court order depend on the type of proceeding, the phase of the proceedings in which they are issued, and the procedural and evidentiary rules that govern the proceedings.

Designated Record Set: A group of records maintained by or for a covered entity, including medical and billing records, used by the covered entity to make decisions about the individual who is the subject of the records.

Direct Treatment Relationship: Relationship between a patient and a healthcare provider that is not an indirect relationship.

Encryption: Use of an algorithmic process to transform data into a form that makes it almost impossible to translate into meaningful data (“de-encryption”) without the use of a confidential process or key.

ePHI: Protected Health Information maintained or transmitted in an electronic format.

FACTA: Fair and Accurate Credit Transactions Act. Includes but is not limited to the Red Flag Rules.

FTC: Federal Trade Commission, agency responsible for enforcing FACTA.

GINA: Genetic Information Nondiscrimination Act. Prohibits employers and health plans from discriminating against individuals based solely on genetic information.

Health Care Operations: Business operations of covered entities, including QA/QI, competency assessments, business planning and management, training new healthcare workers, auditing, and evaluating managed care contracts.

HHS: Department of Health and Human Services

HIO: Health Information Organization. A group of organizations that share health-related information according to established protocols to maintain privacy and security. They are not usually covered entities, but may perform some functions as business associates.

HIPAA: Health Insurance Portability and Accountability Act of 1996. Includes Transactions and Code Sets. National Identifiers, Privacy Rule and Security Rule.

HITECH: Health Information Technology for Economic and Clinical Health Act.

Implementation Specification: A detailed description of the method or approach covered entities can use to meet a particular standard.

Identifiers: Data or other types of information used to establish or verify who an individual is.

Indirect Treatment Relationship: A relationship between a patient and a health care provider in which the health care provider delivers the care based on orders from another provider. The second provider provides products or services or reports the diagnosis to the referring provider, who in turn provides the service, product, or report to the patient. Examples: reference laboratory, imaging center, pathologist, radiologist.

Integrity: The property of information or data that means it has not been altered or destroyed.

 Law Enforcement Official: Officer or employee of an agency of the United States, a political division, or an Indian tribe with the authority to conduct an investigation or inquiry into a potential law violation. Does not include school attendance personnel.

Limited Data Set: Information with all direct identifiers (name, address, phone number, Social Security number, etc.) removed and allowed by HIPAA to be used in research, public health activities, and health operations. May have some “indirect” identifiers, such as date of birth, service dates, and zip code. The partially de-identified information may be disclosed only if there is a “data use agreement” in place, much like a Business Associate Agreement.

Marketing: Communication about a product or service to encourage the recipient of the communication to use the product or service. Excludes communications about products or services provided by the covered entity or health plan, products or services that are specific for the individual’s care or payment, or services performed by a healthcare provider or plan to an individual as a part of that individual’s care. Also excludes oral or written communication when the covered entity does not receive remuneration from a third party for making the communication.

Minimum Necessary: Least amount of information to the fewest people required to deliver healthcare and receive reimbursement for the care.

NEI: National Employer Identifier; tax ID number established by the Internal Revenue Service.

NPI: National Provider Identifier.

NPPES: National Plan and Provider Enumeration Service; agency responsible for establishing and maintaining national plan and provider numbers.

NPP: Notice of Privacy Practices; the document used to explain to your patients how you may use their protected health information and what their rights concerning their PHI are.

OCR: Office for Civil Rights; agency responsible for enforcing the Privacy and Security Rules.

Omnibus Rule or Omnibus Final Rule: HIPAA regulation changes enacted in 2013 to incorporate many of the changes required by the HITECH requirements into the HIPAA regulations.

Personal Representative: Individual with authority to make decisions on behalf of the patient. May be the patient himself or herself, a parent or a guardian.

PHI: Protected Health Information; individually identifiable health information maintained or transmitted by a covered entity in any form or medium. Personnel or employment records are excluded.

Physical Safeguards: Physical measures to protect the electronic information system and the related buildings and equipment from natural and environmental hazards and from unauthorized intrusion.

Privacy: Confidentiality; right of patients to expect information to be protected from unauthorized access, use, or disclosure.

Privacy Officer: Individual within the practice assigned the responsibility of ensuring compliance with the Privacy Rule. May be the same person as the Security Officer.

Psychiatric Information: Data in the medical record pertaining to a patient’s psychiatric diagnosis, treatment, etc. Does not include psychotherapy notes.

Psychotherapy Notes: Notes recorded in any media by a mental health professional concerning conversations during counseling session and separated from other medical records. Excludes prescriptions, times, type and frequency of treatments, results of clinical tests, diagnosis, functional status, treatment plan, symptoms, prognosis, and progress.

Qualified Protective Order: An order of the court or administrative tribunal or stipulation in litigation or administrative proceedings that prohibits parties from using or disclosing PHI for any purpose other than the litigation or proceeding for which the PHI was requested and requires the destruction or return of the PHI to the practice where it originated, including any copies made, at the end of the proceeding or litigation.

Red Flag Rules: Regulations issued by the FTC (Federal Trade Commission), federal bank regulatory agencies, and the National Credit Union Association, requiring financial institutions and creditors to develop and implement written identity theft prevention programs, as part of the Fair and Accurate Credit Transactions (FACT) Act of 2003. The programs must provide for the identification, detection, and response to patterns, practices, or specific activities – known as “red flags” – that could indicate identity theft.

RHIO: Regional Health Information Organization; a group of organizations within a specific geographical area that share healthcare-related information electronically according to national standards. A RHIO typically oversees the means of information exchange and develops healthcare information technology (HIT) standards.

Security: Administrative, physical, and technical safeguards to protect information.

Security Rule: Part of HIPAA that requires entities to evaluate risks and vulnerabilities in their environments and to implement reasonable and appropriate security measures to protect against reasonably anticipated threats or hazards to the security or integrity of e-PHI.

Security Officer: Individual within the practice assigned the responsibility of ensuring compliance with the Security Rule. May be the same person as the Privacy Officer.

Subcontractor: A person or entity to whom a business associate delegates a function, activity, or service, other than in the capacity of a member of the workforce of such business associate.

Subpoena: writ by a government agency, most often a court, that has authority to compel testimony by a witness or production of evidence under a penalty for failure. There are two common types of subpoena:

TPO: Treatment, payment, and health care operations.

Technical Safeguards: The use of technology, policies, and procedures to protect ePHI and controls access to it.

Unsecured PHI: Protected health information in an electronic format that lacks security safeguards such as encryption.

Workforce: All individuals who work in the practice—employees, employers, students, volunteers.

Managed Care Terminology

The following terms are commonly used in the managed care community. The inclusion of any term, however, does not constitute an endorsement or recommendation by DoctorsManagement or any of its subsidiaries or employees.

Accreditation–The process by which an organization recognizes an institution as meeting predetermined standards

Actuarial Soundness–The requirement that the development of capitation rates meet common actuarial principles and rules.

Adjusted Average Per Capita Cost (AAPCC)–The estimated average fee-for-service cost of Medicare benefits for an individual by county of residence. It is based on the following factors: age, sex, institutional status, Medicaid, disability, and end stage renal disease status. HCFA uses the AAPCCs as a basis for making monthly payments to TEFRA contractors.

Adverse Selection–The problem of attracting members who are sicker than the general population, specifically, members who are sicker than was anticipated when developing the rates of reimbursement for medical costs.

Affiliated Provider–a health care provider or facility that is part of the Managed Care Organization’s network, usually having formal arrangements to provide services to the MCO’s member.

Alternative Delivery Systems–A phrase used to describe all forms of health care delivery except traditional fee-for-service, private practice. The term includes HMOs, PPOs, IPAs, and other systems of providing health care.

Ambulatory Care–All types of health services that are provided on an outpatient basis, in contrast to services provided in the home or to persons who are hospital inpatients.

Benefits–The payment for, or health care services provided under terms of a contract with a MCO.

Capitation–A dollar amount established to cover the cost of health care services delivered for a person during a specified length of time. The term usually refers to a negotiated per capita rate to be paid periodically to a health care provider by a MCO. The provider is then responsible for delivering or arranging the delivery of all health services required by the covered person under the conditions of the provider contract. This term may also refer to the amount paid to a MCO > by HCFA or a State.

Carve Out–One or more services excluded from those required to be provided under the capitation rates. These services may be paid on a fee-for-service or other basis.

Case Management–A process and technique to manage the care of specific health care needs (often multiple) in a way that is designed to achieve the optimum patient outcome in the most cost-effective manner.

Case Manager–A nurse, doctor, or social worker who works with patients, providers and insurers to coordinate all services deemed necessary to provide the patient with a plan of medically necessary and appropriate health care.

Closed Access–A managed health care arrangement in which covered persons are required to select providers only from the plan’s participating providers.

Competitive Medical Plan (CMP)–A status, established by TEFRA and granted by the Federal government, to an organization that meets specific requirements enabling that organization to obtain a Medicare risk or cost based contract.

Copayment–A cost-sharing arrangement in which a member pays a specified charge for a specified service (e.g., $10 for an office visit). The member is usually responsible for payment at the time the service is rendered.

Cost Contract–A TEFRA contract payment methodology option by which HCFA pays for the delivery of health services to members based on the HMO’s reasonable cost. The plan receives an interim amount derived from an estimated annual budget, which may be periodically adjusted during the course of the contract to reflect actual cost experience. The plan’s expenses are audited at the end of the contract to determine the final rate the plan should have been paid.

Cost Sharing–A general set of financing arrangements in which a covered member must pay a portion of the costs associated with receiving care. (See also copayment, coinsurance and deductible).

Deductible–A specified amount of money a member must pay before insurance benefits begin. Usually expressed in terms of an “annual” amount.

Diagnosis Related Groups (DRG)–A system of classification for inpatient hospital services based on diagnosis, age, sex, and the presence of complications. It is used as a means of identifying costs for providing services associated with a diagnosis and as a mechanism to reimburse hospital and selected other providers for services rendered.

Employer Mandate–Under the Federal HMO Act, describes conditions when federally qualified HMOs can mandate or require an employer to offer at least one federally qualified HMO plan of each type (IPA/network or group/staff). (Sunsetted in 1995).

EQRO (External Quality Review Organization)–States are required to contract with an entity that is external to and independent of the State and its HMO and HIO contractors to perform an annual review of the quality of services furnished by each HMO or HIO contractor.

Exclusive Provider Organization (EPO)–A term derived from the phrase preferred provider organization (PPO). However, where a PPO generally extends coverage for non-preferred provider services as well as preferred provider services, an EPO provides coverage only for contracted providers; hence, the term exclusive. Technically, many HMOs can also be described EPOs.

Experience Rating–The process of setting rates partially or in whole on evaluating previous claims experience for a specific group or pool of groups.

Federal Medicaid Managed Care Waiver Program–The process used by States to receive permission to implement managed care programs for their Medicaid or other categorically eligible beneficiaries.

Federal Qualification–A status defined by the HMO Act, conferred by HCFA after conducting an extensive evaluation of the HMO’s organization and operations. An organization must be federally qualified or be designated as a CMP (competitive medical plan) to be eligible to participate in Medicare cost and risk contracts. Likewise, an HMO must be federally qualified or State plan defined to participate in the Medicaid managed care program.

Fee-For-Service (FFS)–A payment system by which doctors, hospitals and other providers are paid a specific amount for each service performed as identified by a claim for payment.

Fiscal Soundness–The requirement that managed care organizations have sufficient operating funds, on hand or available in reserve, to cover all expenses associated with services for which they have assumed financial risk.

Gatekeeper–An arrangement in which a primary care provider serves as the patient’s agent, arranges for and coordinates appropriate medical care and other necessary and appropriate referrals.

Group or Network HMO–An HMO that contracts with one or more independent group practice to provide services to its members in one or more locations.

Guaranteed Eligibility–A defined period of time (3-6 months) that all patients enrolled in prepaid health programs are considered eligible for Medicaid, regardless of their actual eligibility for Medicaid. A State may apply to HCFA for a waiver to incorporate this into their contracts.

Health Maintenance Organization (HMO)–An entity that provides, offers or arranges for coverage of designated health services needed by members for a fixed, prepaid premium. There are three basic models of HMOs: group model, individual practice association (IPA), and staff model.

HEDIS–The Healthcare Effectiveness Data and Information Set is a set of performance measures developed to support health plan and Medicaid agency efforts to improve the health status of Medicaid beneficiaries, support the strengthening of health care delivery systems for the Medicaid population, promote standardization of managed care reporting across public and private sectors, and promote the application of performance measurement technology across Medicaid programs.

HIO–An entity that contracts on a prepaid, capitated risk basis to provide comprehensive health services to recipients.

Individual Practice Association (IPA) model HMO–An HMO that contracts with individual practitioners or an association of individual practices to provide health care services in return for a negotiated fee. The individual practice association, in turn, compensates its physicians on a per capita, fee schedule, or other agreed basis.

Insolvency–A legal determination occurring when a managed care plan no longer has the financial reserves or other arrangements to meet its contractual obligations to patients and subcontractors.

Licensing–A process most States employ, which involves the review and approval of applications from HMOs prior to beginning operation in certain areas of the State. Areas examined by the licensing authority include: fiscal soundness, network capacity, MIS, and quality assurance. The applicant must demonstrate it can meet all existing statutory and regulatory requirements prior to beginning operations.

Lock-in–A contractual provision by which members except in cases of urgent or emergency need, are required to receive all their care from the network health care providers.

Managed Care–A system of health care that combines delivery and payment; and influences utilization of services, by employing management techniques designed to promote the delivery of cost-effective health care.

Managed Health Care Plan–An arrangement that integrates financing and management with the delivery of health care services to an enrolled population. It employs or contracts with an organized system of providers which delivers services and frequently shares financial risk.

Medicare Supplement Policy–A health insurance policy that pays certain cost not covered by Medicare such as coinsurance, deductibles.

Network Model HMO–A health care model in which the HMO contracts with more that one physician group or IPA, and may contract with single and multi-specialty groups that work out of their own office facility. The network may or may not provide care exclusively for the HMO’s members.

Open Access–A term describing a member’s ability to self-refer for specialty care. Open access arrangements allow a member to see a participating provider without a referral from another doctor. Also called open panel.

Open Enrollment Period–A period during which subscribers in a health benefit program have an opportunity to select among health plans being offered to them, usually without evidence of insurability or waiting periods.

Outcome measurement–A process of systematically measuring individual or collective clinical treatment and response to that treatment.

Out-of -pocket expenses–Costs borne by the member that are not covered by health care plan.

PCCM–A Primary Care Case Management program is a Freedom of Choice Waiver program, under the authority of section 1915(b) of the Social Security Act. States contract directly with primary care providers who agree to be responsible for the provision and/or coordination of medical services to Medicaid recipients under their care. Currently, most PCCM programs pay the primary care physician a monthly case management fee in addition to receiving fee-for-services payment.

Peer Review–The evaluation of the quality of the total health care provided by Plan medical staff by equivalently trained medical personnel.

Peer Review Organization (PRO)–An organization established by the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) to review quality of care and appropriateness of admissions, readmissions and discharges for Medicare and Medicaid.

PHP–A Prepaid Health Plan is a entity that either contracts on a prepaid, capitated risk basis to provide services that are not risk-comprehensive services, or contracts on a non-risk basis. Additionally, some entities that meet the above definition of HMOs are treated as PHPs through special statutory exemptions.

Point-Of-Service Plan–A health services delivery organization that offers the option to its members to choose to receive a service from participating or a nonparticipating provider. Generally the level of coverage is reduced for services associated with the use of non-participating providers.

Preferred Providers–Physicians, hospitals, and other health care providers who contract to provide health services to persons covered by a particular health plan.

Preferred Provider Organization–A health care delivery system that contracts with providers of medical care to provide services at discounted fees to members. Members may seek care form non-participating providers but generally are financially penalized for doing so by the loss of the discount and subjection to copayments and deductibles.

Premium –Money paid out in advance for insurance coverage.

Prepayment–A method of paying for the cost of health care services in advance of their use.

Preventive health care–Health care that seeks to prevent or foster early detection of disease and morbidity and focuses on keeping patients well in addition to health them while they are sick.

Primary Care Network (PCN)–A group of primary care physicians who share the risk of providing care to members of a given health plan.

Primary Care Provider (PCP)–The provider that serves as the initial interface between the member and the medical care system. The PCP is usually a physician, selected by the member upon enrollment, who is trained in one of the primary care specialties who treats and is responsible for coordinating the treatment of members assigned to his/her plan. (See Gatekeeper)

Professional Review Organization–An organization which reviews the services provided to patients in terms of medical necessity professional standards; and appropriateness of setting.

QARI –The Quality Assurance Reform Initiative was unveiled in 19993 to assist States in the development of continuous quality improvement systems, external quality assurance programs, internal quality assurance programs, and focused clinical studies.

Qualified Medicare Beneficiary (QMB)— A person whose income level is such that the state pays the Medicare Part B Premiums, deductibles and copayments.

Quality Assurance–A formal methodology and set of activities designed to access the quality of services provided. Quality assurance includes formal review of care, problem identification, corrective actions to remedy any deficiencies and evaluation of actions taken.

Reinsurance–An insurance arrangement whereby the MCO or provider is reimbursed by a third party for costs exceeding a pre-set limit, usually an annual maximum.

Risk Adjustment–A system of adjusting rates paid to managed care providers to account for the differences in beneficiary demographics, such as age, gender, race, ethnicity. Medical condition, geographic location, at-risk population (i.e. homeless), etc.

Risk Contract–A contract payment methodology between HCFA and an HMO or CMP that requires the delivery of (at least) all covered services to members as medically necessary in return for a fixed monthly payment rate from the government and (often) a premium paid by the enrollee. The HMO is then liable for those contractually offered services without regard to cost. (Note: Medicaid beneficiaries enrolled in risk contracts are not required to pay premiums.)

Shared Savings–A provision of most prepaid health care plans where at least part of the providers’ income is directly linked to the financial performance of the plan. If costs are lower than projections, a percentage of these savings are referred to the providers.

Staff Model HMO–This model employs physicians to provide health care to its members. All premiums and other revenues accrue to the HMO, which compensates physicians by salary.

Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)–The Federal law that created the current risk and cost contract provisions under which health plans contract with HCFA.

Utilization Management–The process of evaluating the necessity, appropriateness and efficiency of health care services against established guidelines and criteria.

Utilization Review (UR)–A formal review of utilization for appropriateness of health care services delivered to a member on a prospective, concurrent or retrospective basis.

OSHA Glossary

The following terms are commonly used in OSHA Compliance. The inclusion of any term, however, does not constitute an endorsement or recommendation by DoctorsManagement or any of its subsidiaries or employees.

Administrative Controls are controls that alter the way the work is done, including timing of work, policies and other rules, and work practices such as standards and operating procedures (including training, housekeeping, equipment maintenance, and personal hygiene practices).

Airborne Pathogens are infectious agents that are spread through small infectious particles such as droplet nuclei.

Bloodborne Pathogens means pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV).

Chemical Hygiene Plan means a written program developed and implemented by the employer that sets forth procedures, equipment, personal protective equipment and work practices that (i) are capable of protecting employees from the health hazards presented by hazardous chemicals used in that particular workplace and (ii) meets the requirements of paragraph (e) of the Chemical Hygiene Plan within the Hazard Communication Standard. This is usually applicable only in free-standing laboratories.

Consumer Products are cleaning, medical and office products that are also often used in the home. A substance is considered a consumer product if it is 1) defined as such under the Consumer Products Safety Act, 2) used in the workplace as intended by the manufacturer, and 3) used with the same frequency and duration of exposure expected of a typical consumer. The Compliance Safety and Health Officer must consider whether use of consumer products in the workplace greatly exceeds normal conditions of use or if the use is different than originally intended for the product.

Contaminated Laundry means laundry that has been soiled with blood or other potentially infectious materials or may contain sharps.

Contaminated Sharps means any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires.

Employer means a person engaged in a business affecting commerce who has employees.

Employee means an employee of an employer who is employed in a business of his employer that affects commerce.

Energy Source is any source of electrical, mechanical, hydraulic, pneumatic, chemical, thermal, or other energy.

Engineering Controls include designs or modifications to plants, equipment, ventilation systems, and processes that reduce the source of exposure (e.g., sharps disposal containers, self-sheathing needles, safer medical devices such as sharps with engineered sharps injury protections and needleless systems) and that isolate or remove the bloodborne pathogens hazard from the workplace.  Other examples include process control, enclosure and/or isolation of hazards, and ventilation.

Ergonomics is the science of fitting workplace conditions and job demands to the capabilities of the working population.

Exposure Incident means a specific eye, mouth, or other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee’s duties.

Fire Brigade (private fire department, industrial fire department) means an organized group of employees who are knowledgeable, trained, and skilled in at least basic fire fighting operations.

Fire Brigade Training means the process of making one proficient through instruction and hands-on practice in the operation of equipment, including respiratory protection equipment, that is expected to be used in the performance of assigned duties.

General Duty Clause

(a) Each employer

(1) shall furnish to each of his employees employment and a place of employment which are free

from recognized hazards that are causing or are likely to cause death or serious physical harm to

his employees;

(2) shall comply with occupational safety and health standards promulgated under this Act.

(b) Each employee shall comply with occupational safety and health standards and all rules, regulations, and orders issued pursuant to this Act which are applicable to his own actions and conduct.

Hazard is a situation in a place of employment with the potential of causing illness or injury to employees that poses a level of threat to health or safety.

Hazard Category is the division of criteria within each hazard class, e.g., oral acute toxicity and flammable liquids include four hazard categories.

Hazard Classification is used to identify the relevant data regarding the hazards of a chemical, review those data to ascertain the hazards associated with the chemical, and decide whether the chemical will be classified as hazardous according to the definition of hazardous chemical in the new standard.

Hazard Control is a way to protect workers from exposure to a substance or system. Examples include elimination, substitution, work practices, personal protective equipment, and engineered controls.

Hazardous Chemical means any chemical which is a physical hazard or a health hazard. Hazardous chemical means a chemical for which there is statistically significant evidence based on at least one study conducted in accordance with established scientific principles that acute or chronic health effects may occur in exposed employees. The term “health hazard” includes chemicals which are carcinogens, toxic or highly toxic agents, reproductive toxins, irritants, corrosives, sensitizers, hepatotoxins, nephrotoxins, neurotoxins, agents which act on the hematopoietic system, and agents which damage the lungs, skin, eyes, or mucous membranes.

Hazard Statement means a statement assigned to a hazard class and category that describes the nature of the hazard(s) of a chemical, including, where appropriate, the degree of hazard.

Hazard Warning means any words, pictures, symbols, or combination thereof appearing on a label or other appropriate form of warning which convey the specific physical and health hazard(s), including target organ effects of the chemical(s) in the container(s). (See the definitions for “physical hazard” and “health hazard” to determine the hazards which must be covered.)

Health Hazard means a chemical for which there is statistically significant evidence based on at least one study conducted in accordance with established scientific principles that acute or chronic health effects may occur in exposed employees. The term “health hazard” includes chemicals which are carcinogens, toxic or highly toxic agents, reproductive toxins, irritants, corrosives, sensitizers, hepatotoxins, nephrotoxins, neurotoxins, agents which act on the hematopoietic system, and agents which damage the lungs, skin, eyes, or mucous membranes.

I2P2 (Injury and Illness Prevention Program) is OSHA’s plans to improve its effectiveness by looking at successful companies and encouraging all employers to initiate and maintain a safety and health program with systematic policies, procedures, and practices to recognize hazards and protect employees from occupational safety and health hazards.

Identity means any chemical or common name which is indicated on the material safety data sheet (SDS) for the chemical. The identity used shall permit cross-references to be made among the required list of hazardous chemicals, the label and the SDS.

Independent Contractors are companies that provide a service, such as radiology or housekeeping, to host employers. They provide supervisory personnel, as well as rank-and-file workers, to carry out the service. These companies and the host employers are responsible for complying with all provisions of the standard in accordance with the multi-employer worksite guidelines of CPL 2-0.124, Multi-Employer Citation Policy.

Immediate Use means that the hazardous chemical will be under the control of and used only by the person who transfers it from a labeled container and only within the work shift in which it is transferred.

Ionizing Radiation includes alpha rays, beta rays, gamma rays, X-rays, neutrons, high-speed electrons, high-speed protons, and other atomic particles; but such term does not include sound or radio waves, or visible light, or infrared or ultraviolet light.

Label Elements are the specified pictogram, hazard statement, signal word and precautionary statement for each hazard class and category.

Laboratory means a facility where the “laboratory use of hazardous chemicals” occurs. It is a workplace where relatively small quantities of hazardous chemicals are used on a non-production basis.

Laboratory Scale means work with substances in which the containers used for reactions, transfers, and other handling of those substances are designed to be easily and safety manipulated by one person. “Laboratory scale” excludes those workplaces whose function is to produce commercial quantities of materials.

Licensed Healthcare Professional is a person whose legally permitted scope of practice allows him or her to independently perform the activities required by paragraph (f) Hepatitis B Vaccination and Post-exposure Evaluation and Follow-up.

Lockout is the placement of a lockout device on an energy isolating device, in accordance with an established procedure, ensuring that the energy isolating device and the equipment being controlled cannot be operated until the lockout device is removed.

Medical Monitoring is testing a worker to determine if an exposure has occurred and if so, to what extent the employee has been harmed.

Material Safety Data Sheet (MSDS) means written or printed material concerning a hazardous chemical which is prepared in accordance with the Hazard Communication Standard.

Non-ionizing Radiation is described as a series of energy waves composed of oscillating electric and magnetic fields traveling at the speed of light. Non-ionizing radiation includes the spectrum of ultraviolet (UV), visible light, infrared (IR), microwave (MW), radio frequency (RF), and extremely low frequency (ELF).

Other Potentially Infectious Materials means (1) the following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; (2) any unfixed tissue or organ (other than intact skin) from a human (living or dead); and (3) HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.

Personal Protective Equipment is specialized clothing or equipment worn by an employee for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment.

Physical Hazard means a chemical for which there is scientifically valid evidence that it is a combustible liquid, a compressed gas, explosive, flammable, an organic peroxide, an oxidizer, pyrophoric, unstable (reactive) or water-reactive.

Pictogram means a composition that may include a symbol plus other graphic elements, such as a border, background pattern, or color, that is intended to convey specific information about the hazards of a chemical.  Eight pictograms are designated under this standard for application to a hazard category.

Precautionary Statement means a phrase that describes recommended measures that should be taken to minimize or prevent adverse effects resulting from exposure to a hazardous chemical, or improper storage or handling.

Process Control involves changing the way a job activity or process is done to reduce the risk. Monitoring should be done before as well as after the change is implemented to make sure the changes did result in lower exposures.

Product Identifier is the name or number used for a hazardous chemical on a label or in the SDS. It provides a unique means by which the user can identify the chemical. 

Radiation (ionizing) includes alpha rays, beta rays, gamma rays, X-rays, neutrons, high-speed electrons, high-speed protons, and other atomic particles; but such term does not include sound or radio waves, or visible light, or infrared or ultraviolet light.

Regulated Waste means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.

Safety Data Sheet (SDS) means written or printed material concerning a hazardous chemical that is prepared in accordance with paragraph (g) of this section.

Self-employed refers to someone who works for himself/herself instead of an employer, but drawing income from a trade or business that they operate personally.

Sharps with Engineered Sharps Injury Protections (SESIPs) are defined as a non-needle sharp or a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident.

Signal Word means a word used to indicate the relative level of severity of hazard and alert the reader to a potential hazard on the label. The signal words used in this section are “danger” and “warning.” “Danger” is used for the more severe hazards, while “warning” is used for the less severe.

Tagout Device is a prominent warning device, such as a tag and a means of attachment, which can be securely fastened to an energy isolating device in accordance with an established procedure to indicate that the energy isolating device and the equipment being controlled may not be operated until the tagout device is removed.

Universal Precautions is an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if they are known to be infectious for the HIV, HBV, and HCV viruses and/or other bloodborne pathogens.

Work Practice Controls means controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique).

Work Area means a room or defined space in a workplace where hazardous chemicals are produced or used and where employees are present.

Workplace means an establishment, job site, or project at one geographical location containing one or more work areas.

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