Value-Based Care Dictionary

CHESS Value-based Care Dictionary

Download Value-Based Care Dictionary pdf here


ACAAffordable Care ActComprehensive health care reform law enacted in March 2010, addressing health insurance coverage, health care costs, and preventive care.
ACOAccountable Care OrganizationGroups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients.
APMAlternative Payment ModelPayment approach that gives added incentive payments to provide high-quality and cost-efficient care.
Attribution Assignment of the results of a measure to an individual, group, or organization responsible for the decisions, costs, and outcomes.
CINClinically Integrated NetworkSelective partnership of physicians collaborating with hospitals to deliver evidence-based care, improve quality, efficiency, and coordination of care, and demonstrate value to the market.
DHHSDepartment of Health & Human ServicesDepartment created to protect the health of Americans and provide essential human services.
FFSFee for ServicePayment model where services are unbundled and paid for individually.
FQHCFederally Qualified Health CenterFederally funded health centers that focus on serving underserved populations or areas.
HIPAAHealth Insurance Portability and Accountability Act of 1996Federal law that ensures protection of sensitive patient health information.
HMOHealth Maintenance OrganizationOne of four types of Medicare Advantage plans. An HMO generally requires beneficiary to use in-network providers.
MAOMedicare Advantage OrganizationPublic or private entity organized and licensed by CMS as a risk-bearing entity.
P4PPay for PerformanceThe payment model in which providers are reimbursed based upon the quality of care provided.
PBPM/PMPMPer Beneficiary/Member Per MonthUnit of measurement, usually in dollars, to indicate amount per patient.
PCPPrimary Care ProviderHealth care practitioner who coordinates, or helps, a patient access a range of health care services.
PFFSPrivate Fee-for-ServiceMedicare Advantage plan offered by a private insurance company.
PFSPhysician Fee ScheduleCMS rule that updates payment policies, payment rates, and other provisions for services.
PHIProtected Health InformationRelates to the past, present, or future condition of an individual. Includes demographic data, medical histories, test results, and other information used to identify a patient.
PPOPreferred Provider OrganizationOne of four types of Medicare Advantage plan. PPOs allow a person the flexibility of choosing either in- or out-of-network providers.
SSShared SavingsPayment strategy that offers incentives for providers to reduce health care spending for a defined patient population by offering them a percentage of any net savings realized.
TINTax Identification NumberNumber assigned by IRS for tax purposes.


CAHPSConsumer Assessment of Healthcare Providers and SystemsSurvey tool used to ask patients about their health care experiences.
CQMClinical Quality MeasureTools that help measure and track the quality of health care services.
eCQMElectronic Clinical Quality MeasuresUse data electronically extracted from EHRs to measure the quality of health care provided.
HEDISHealthcare Effectiveness Data and Information SetTool used to measure performance on important dimensions of care and service.
MIPSMerit-Based Incentive Payment SystemProgram that determines Medicare fee for service payment adjustments.
NCQANational Committee for Quality AssuranceNon-profit dedicated to improving health care quality. Maintains HEDIS score and researches quality measures.
PMPM/PMPYPer Member Per Month/YearRefers to the dollar amount paid each month for each individual enrolled in a managed care plan, often referred to as capitation.
PYPerformance Year12-month period beginning during the agreement period, unless otherwise specified or noted in the contract.
RARReadmission RatePercentage of admitted patients who return to the hospital within 7 days of discharge.
WIQMWeb Interface Quality MeasureClinical quality measures reported by an ACO to Medicare based on the patient population.


ASCAmbulatory Surgical CenterHealth care facility providing same-day surgical care.
ACSCAmbulatory Care Sensitive ConditionsConditions for which hospital admission could be prevented by timely and effective outpatient care.
APCAdvanced Practice ClinicianIncludes advanced practice registered nurses and physician assistants.
APPAdvanced Practice ProviderProvider who is not a physician but performs medical activities typically performed by a physician. Most commonly a nurse practitioner or physician assistant.
AWVAnnual Wellness VisitMedicare covers the AWV, a preventive wellness visit.
CCMChronic Care ManagementNon-face-to-face services provided to Medicare beneficiaries who have multiple (two or more) significant chronic conditions.
DTPDrug Therapy ProblemsClinical problems related to the use of medications.
EHRElectronic Health RecordElectronic database that stores confidential patient information.
EMRElectronic Medical RecordDigital version of a patient’s chart.
SNFSkilled Nursing FacilityIn-patient rehabilitation and medical treatment center staffed with trained medical professions.
TCMTransitional Care ManagementServices that address the hand-off period between inpatient and community settings.
TOCTransitions of CareProcess of transferring a patient’s care from one setting or level of care to another.
SDOHSocial Determinants of HealthConditions in the places where people are born, live, learn, and work that affect a wide range of health, functioning, and quality-of-life outcomes and risks.
HPIHistory of Present IllnessDescription of development of patient’s present illness.
LTCLong Term CareServices to meet needs of people with chronic illness or disability who cannot care for themselves for long periods.


CDIClinical Documentation ImprovementProcess of improving health care records to ensure improved patient outcomes, data quality, and accurate reimbursement.
HCCHierarchical Condition CategoryMedical codes linked to specific clinical diagnoses.
ICD-11International Classification of DiseasesMedical classification list by the World Health Organization.
RADV AuditsRisk Adjustment Data Validation AuditsProcess of verifying diagnosis codes submitted for payment with the support of medical record documentation.
RAFRisk Adjustment FactorMedical risk adjustment model used by CMS to represent a patient’s health status.


CMSCenters for Medicare and Medicaid ServicesFederal agency responsible for administering Medicare and overseeing state administration of Medicaid.
CMMICenter for Medicare & Medicaid InnovationThe innovation center was created for the purpose of testing “innovative payment and service delivery models to reduce program expenditures…while preserving or enhancing the quality of care.”
GPDCGlobal and Professional Direct Contracting ModelSet of two voluntary risk-sharing options aimed at reducing expenditures and preserving quality of care for beneficiaries in Medicare FFS.
MAMedicare AdvantageType of Medicare health plan offered by a private company that contracts with Medicare to provide Part A and B benefits.
MACRAMedicare Access and CHIP Reauthorization Act of 2015Changed how Medicare pays physicians who provide care to Medicare beneficiaries.
MBIMedicare Beneficiary IdentifierEvery person with traditional Medicare is assigned an MBI.
MBR/MLR/MERMedical Benefit Ratio Medical Loss Ratio Medical Expense RatioAmount of premium revenue spent on medical care and services.
MIPPAMedicare Improvements for Patients and Providers Act of 2008Supports states through grants to provide outreach and assistance to eligible Medicare beneficiaries to apply for benefits programs that help lower cost of their premiums and deductibles.
MIPSMerit-Based Incentive Payment SystemOne option of the MACRA Quality Payment Program. Comprised of quality, cost, improvement activities, and advanced care information.
MSPBMedicare Spending per BeneficiaryAssesses Medicare Part A and Part B payments for services provided to a Medicare beneficiary during a spending-per-beneficiary episode. Evaluates hospitals’ efficiency relative to the efficiency of the median hospital.
MSSPMedicare Shared Savings ProgramVoluntary program that encourages doctors, hospitals, and other health care providers to come together as an ACO to give coordinated, high quality care to their Medicare beneficiaries.
NGACONextGen or Next GenerationInitiative for ACOs that were experienced in coordinating care for Medicare populations. It allowed these provider groups to assume higher levels of financial risk and reward.

Data + Tech

CDSClinical Decision SupportA health IT system that is designed to provide physicians with clinical decision-making tasks.
CEHRTCertified Electronic Health Record TechnologyEHR that’s demonstrated the tech capability, functionality, and security requirements required by DHHS.
HIEHealth Information ExchangeUse of technology to manage current and historical information related to a person’s care.
HITHealth Information TechnologyThe exchange of health information electronically, with the goal of improving quality of care by reducing costs, errors, and inefficiency.

Download Value-Based Care Dictionary pdf here