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A term used to describe a physician who has passed an examination given by a medical specialty board and who ahs been certified as a specialist in that medical area.

CREDENTIALING

A process of review to approve a provider who applies to participate in a health plan.  Specific criteria and prerequisites are applied in determining initial and ongoing participation in the health plan.

GRIEVANCE PROCEDURE

The process by which a health plan member or participating provider can air complaints and seek remedies.  

HEALTH PLAN EMPLOYER DATA AND INFORMATION SET (HEDIS)

A core set of performance measures to assist employers and other health purchasers in understanding the value of health care purchases and evaluating health plan performance.

JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS (JCAHO)

A private, not-for-profit organization that evaluates and accredits hospitals and other health care organizations providing home care, mental health care, ambulatory care and long term services.

As used herein refers to physicians employed by HMO’s in the position of medical director for the HMO, though the same characteristics may also apply to other types of MCO’s.

MEDICAL PRACTICE GUIDELINES

Criteria used by HMO’s for uniformity in the decision-making process for utilization and quality issues.

NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA)

A non-profit organization dedicated to assessing and reporting the quality of care delivered by managed care organizations.  Developed HEDIS.

PEER REVIEW

The evaluation of quality of total health care provided, by medical staff with equivalent training. 

PEER REVIEW ORGANIZATION

An entity 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.  These organizations are held responsible for maintaining and lowering admission rates, and reducing lengths of stay while insuring against inadequate treatment.

PHYSICIAN EXECUTIVES

As used herein refers to Medical Directors of HMO’s, though the same characteristics may also apply to other types of MCO’s.