This glossary contains key industry terms and their definitions to assist AI understanding and response generation.

Accountable Care Organization, a group of doctors, hospitals, and other providers that voluntarily band together to coordinate patient care and improve quality while controlling costs. ACOs often share responsibility for patient outcomes and may share in savings achieved (especially in Medicare programs)​

Admission, Discharge, and Transfer, referring to the key patient events in healthcare facilities. In practice, an “ADT system” or feed tracks patient admissions to a hospital, discharges from care, and transfers between care settings, ensuring that care teams have up-to-date information on patient movements​

Consumer Assessment of Healthcare Providers and Systems, a standardized survey program that asks patients about their healthcare experiences and satisfaction. CAHPS scores are used by health plans and regulators to measure quality from the patient’s perspective (for example, in Medicare star ratings)​

Fast Healthcare Interoperability Resources, a modern standard for exchanging healthcare information electronically. FHIR (developed by HL7) defines a set of data formats and an API for sharing health records – allowing different health IT systems (like EHRs and apps) to exchange data seamlessly and support interoperability​

Hierarchical Condition Category, a risk adjustment coding system used in Medicare Advantage and some Affordable Care Act plans. HCCs group related diagnoses into categories of illness severity; they are used to predict future healthcare costs for patients and adjust payments to health plans or providers based on the expected risk of enrollees​

Healthcare Effectiveness Data and Information Set, a set of standardized performance measures developed by NCQA to evaluate the quality of care and services provided by health plans. HEDIS includes dozens of measures (e.g. cancer screening rates, diabetes care metrics) that allow for benchmarking and comparing health plan performance on delivering effective care

Health Information Exchange, which is the electronic sharing of health-related information among organizations. An HIE can refer to a network or platform that allows hospitals, clinics, labs, and insurers to exchange patient data (such as lab results or ADT notifications) securely, with the goal of improving care continuity and reducing duplicate services

Health Risk Assessment (also called a health risk appraisal), which is a questionnaire used to evaluate an individual’s health status and risk factors. Members often fill out an HRA when enrolling in a health plan or care management program – the survey covers medical history, lifestyle, and preventive needs, and the results help care managers identify which patients may benefit from wellness programs or interventions

Managed Care Organization, a broad term for a health plan or network that manages cost, quality, and access to healthcare services for its members. An MCO integrates the financing and delivery of care – for example, an HMO or PPO is an MCO that contracts with a limited network of providers and uses tools like utilization management and care coordination to provide cost-effective, appropriate care​

Medical Loss Ratio, which is the percentage of premium dollars an insurance plan spends on members’ medical claims and quality improvements, as opposed to administrative costs or profit. For instance, an MLR of 85% means 85¢ of every premium dollar is used for healthcare services. The Affordable Care Act requires health plans to meet minimum MLR thresholds (e.g. 80% for individual plans; 85% for large group and Medicare Advantage), issuing rebates to consumers if they fall short

National Committee for Quality Assurance, an independent nonprofit organization that accredits and certifies healthcare organizations and develops quality standards. NCQA is known for programs like health plan accreditation and HEDIS measures – it works to improve healthcare quality by measuring performance and recognizing organizations that meet rigorous quality benchmarks​

Pharmacy Benefit Manager, a company that administers prescription drug benefits on behalf of health insurers or employers. PBMs manage drug formularies (the list of covered medications), negotiate discounts and rebates with pharmaceutical manufacturers, process pharmacy claims, and often run mail-order pharmacies – all aimed at controlling medication costs and ensuring appropriate use of drugs​