Glossary of Terms

Capitation
A payment system in which health care providers (practitioners, hospitals, pharmacists, etc.) receive a fixed payment per member per month (or year), regardless of how many or few services the patient uses.
Care Coordination
An activity by a person or entity (e.g., Health Homes) formally designated as primarily responsible for coordinating services furnished by providers involved in a member's care. This coordination may include care provided by network or non-network providers. Organizing care involves the marshaling of personnel and other resources needed to carry out all required member care activities; it is often facilitated by the exchange of information among participants responsible for different aspects of the member's care.
Care Management
Overall system of benefit package service/management administered by the Plan and which encompasses utilization management, care coordination, facilitating continuity of care during care transitions (i.e., changes in levels of care, aging out of the Children's System of Care or member relocation), management of the quality of care, chronic condition management, and independent peer review.
Case Management
A process managed care plans may use to review the care that patients receive. The goal of case management is to ensure that patients receive the appropriate service from the right provider, at the right time, and in the least costly setting.
Case Rate
A payment system in which the managed care plan pays health care providers an all-inclusive fee to provide care for a patient, based on the patient's diagnosis, or the medical treatments for an agreed upon episode of care.
Category of Service (COS)
A 4-digit code that denotes the type of claim to be entered.
Center for Integrated Health Solutions (CIHS)
A part of SAMHSA, this center promotes the development of integrated primary and behavioral health services to better serve individuals with mental health and substance use conditions.
Certified Community Behavioral Health Clinic (CCBHC)
Planning grant under which New York will engage stakeholders and coordinate activities across agencies to ensure services are accessible and available.
Claims Form
Documentation (electronic or paperwork) that patients and health care providers file with managed care plans in order to receive payment for services.
Clinical Pathway
A medical "roadmap" that helps health care providers identify the most appropriate course of treatment for a specific patient, based on that patient's clinical situation.
Clinical Practice Guidelines
Systematically developed statements regarding assessment and intervention practices. These guidelines were created to assist with practitioner and patient/consumer decisions about appropriate health care for specific circumstances. The goals of clinical practice guidelines are to describe appropriate care based on the best available scientific evidence and broad consensus; reduce inappropriate variation in practice; provide a more rational basis for referral; provide a focus for continuing education; promote efficient use of resources; and act as a focus for quality control.
Coinsurance
The portion of health care costs not paid by the managed care plan, for which the consumer is responsible. Coinsurance usually is expressed as a fixed proportion of the managed care plan's allowable charge. For example, if a plan pays 80 percent of its allowable charge for a covered service, the consumer is responsible for the remaining 20 percent as coinsurance.
Collaborative Care
The collaborative care model is an evidence-based approach for integrating physical and behavioral health services that can be implemented within a primary care-based setting. It is a multicomponent, system-level intervention that includes care coordination and care management; regular and proactive monitoring using validated clinical rating scales; and routine, systematic caseload reviews and monitoring by psychiatrists who are also available to consult with individuals who do not show improvement. Collaborative care has been shown to improve symptoms, treatment adherence, quality of life/functional status, and satisfaction with care for individuals with depression.
Community Based Organization (CBO)
CBOs are organizations that work to improve the well-being of their local residents. Specifically, these organizations provide a wide variety of social and support services to individuals, families, and populations that range across housing, job placement, transportation, legal services and mental health services.
Community Inclusion
The full participation by an individual living with mental illness and/or substance use disorders in living arrangements, activities, organizations and groups of his/her choosing in the community.
Community Support Specialist (CSS)
Responsible for arranging/providing services to consumers that encourage and promote healthy functioning, recovery efforts, consumer independence/self-care and responsibility.
Community Technical Assistance Center (CTAC)
A training, consultation and educational resource center serving all behavioral health agencies in NYS.
Consumer
A member who is receiving or has received mental health/substance use disorder services.
Consumer Assessment of Healthcare Providers and Systems (CAHPS)
A survey that asks consumers to report on and evaluate their experiences with health care.
Continuous Quality Improvement (CQI)
A quality management process where health care providers constantly evaluate the administration and clinical aspects of the services they provide and strive to improve, become more efficient and effective. Data and advance planning are critical to this process.
Contracted Provider
A hospital, practitioner, network of hospitals and practitioners, or other healthcare providers who enter into a legal agreement with a managed care plan to care for the plan's members for negotiated prices.
Coverage
Decision making process that identifies what services or products are benefits under the employer's or consumer's contract with the plan. Covered products or services are eligible to be paid for by the plan.
Credentialed Alcoholism and Substance Abuse Counselor (CASAC)
Individuals who is credentialed to provide alcoholism and substance abuse counseling services in approved work settings as defined by NYS OASAS.
Credentialing
A system used by managed care plans to assess the qualifications of practitioners or other health care providers who are contracted.
Cultural Competence
Having the capacity to provide appropriate services/care within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities.