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Glossary

Glossary

This glossary explains terms found on the cms.hhs.gov web site, but it is not a legal document.

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Term Definition
ADMINISTRATIVE CODE SETS

Code sets that characterize a general business situation, rather than a medical condition or service. Under HIPAA, these are sometimes referred to as non-clinical or non-medical code sets. Compare to medical code sets.

ADMINISTRATIVE SERVICES ONLY

An arrangement whereby a self-insured entity contracts with a Third Party Administrator (TPA) to administer a health plan.

ADMINISTRATIVE SIMPLIFICATION

Title II, Subtitle F, of HIPAA which authorizes HHS to: (1) adopt standards for transactions and code sets that are used to exchange health data; (2) adopt standard identifiers for health plans, health care providers, employers, and individuals for use on standard transactions; and (3) adopt standards to protect the security and privacy of personally identifiable health information.

ADMINISTRATIVE SIMPLIFICATION COMPLIANCE ACT

Signed into law on December 27, 2001 as Public Law 107-105, this Act provides a one-year extension to HIPAA "covered entities" (except small health plans, which already have until October 16, 2003) to meet HIPAA electronic and code set transaction requirements. Also, allows the Secretary of HHS to exclude providers from Medicare if they are not compliant with the HIPAA electronic and code set transaction requirements and to prohibit Medicare payment of paper claims received after October 16, 2003, except under certain situations.


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Term Definition
BUSINESS ASSOCIATE

A person or organization that performs a function or activity on behalf of a covered entity, but is not part of the covered entity's workforce. A business associate can also be a covered entity in its own right. Also see Part II, 45 CFR 160.103.

BUSINESS RELATIONSHIPS

The term agent is often used to describe a person or organization that assumes some of the responsibilities of another one. This term has been avoided in the final rules so that a more HIPAA-specific meaning could be used for business associate.


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Term Definition
CENTERS FOR MEDICARE & MEDICAID SERVICES

The HHS agency responsible for Medicare and parts of Medicaid. Centers for Medicare & Medicaid Services has historically maintained the UB-92 institutional EMC format specifications, the professional EMC NSF specifications, and specifications for various certifications and authorizations used by the Medicare and Medicaid programs. CMS is responsible for oversight of HIPAA administrative simplification transaction and code sets, health identifiers, and security standards. CMS also maintains the HCPCS medical code set and the Medicare Remittance Advice Remark Codes administrative code set.

CHAIN OF TRUST AGREEMENT

Contract needed to extend the responsibility to protect health care data across a series of sub-contractual relationships.

CLAIM STATUS CODES

A national administrative code set that identifies the status of health care claims. This code set is used in the X12N 277 Claim Status Inquiry and Response transaction, and is maintained by the Health Care Code Maintenance Committee.

CMS-1450

The uniform institutional claim form.

CMS-1500

The uniform professional claim form.

CODE OF FEDERAL REGULATIONS

The official compilation of federal rules and requirements.

CODE SET

Under HIPAA, this is any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes. This includes both the codes and their descriptions. Also see Part II, 45 CFR 162.103.

COMPLIANCE DATE

Under HIPAA, this is the date by which a covered entity must comply with a standard, an implementation specification, or a modification. This is usually 24 months after the effective data of the associated final rule for most entities, but 36 months after the effective data for small health plans. For future changes in the standards, the compliance date would be at least 180 days after the effective data, but can be longer for small health plans and for complex changes.

COORDINATION OF BENEFITS

Process for determining the respective responsibilities of two or more health plans that have some financial responsibility for a medical claim. Also called cross-over.

COVERED ENTITY

Under HIPAA, this is a health plan, a health care clearinghouse, or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction.

CURRENT DENTAL TERMINOLOGY

A medical code set of dental procedures, maintained and copyrighted by the American Dental Association (ADA), and adopted by the Secretary of HHS as the standard for reporting dental services on standard transactions.

CURRENT PROCEDURAL TERMINOLOGY

A medical code set of physician and other services, maintained and copyrighted by the American Medical Association (AMA), and adopted by the Secretary of HHS as the standard for reporting physician and other services on standard transactions.


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Term Definition
DATA CONDITION

A description of the circumstances in which certain data is required.

DATA CONTENT

Under HIPAA, this is all the data elements and code sets inherent to a transaction, and not related to the format of the transaction.

DATA ELEMENT

Under HIPAA, this is the smallest named unit of information in a transaction.

DATA MAPPING

The process of matching one set of data elements or individual code values to their closest equivalents in another set of them. This is sometimes called a cross-walk.

D-CODES

Subset of the HCPCS Level II medical codes identifying certain dental procedures. It replicates many of the CDT codes and will be replaced by the CDT. Descriptor: The text defining a code in a code set.

DESCRIPTOR

The text defining a code in a code set.

DESIGNATED CODE SET

A medical code set or an administrative code set that is required to be used by the adopted implementation specification for a standard transaction.

DESIGNATED STANDARD

A standard which HHS has designated for use under the authority provided by HIPAA.

DESIGNATED STANDARD MAINTENANCE ORGANIZATION

An organization, designated by the Secretary of the U.S. Department of Health & Human Services, to maintain standards adopted under Subpart I of 45 CFR Part 162. A DSMO may receive and process requests for adopting a new standard or modifying an adopted standard.

DIRECT DATA ENTRY

Under HIPAA, this is the direct entry of data that is immediately transmitted into a health plan's computer.


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Term Definition
EDI TRANSLATOR

A software tool for accepting an EDI transmission and converting the data into another format, or for converting a non-EDI data file into an EDI format for transmission.

EFFECTIVE DATE

Under HIPAA, this is the date that a final rule is effective, which is usually 60 days after it is published in the Federal Register.

ELECTRONIC DATA INTERCHANGE

Refers to the exchange of routine business transactions from one computer to another in a standard format, using standard communications protocols.

ELECTRONIC MEDIA CLAIMS

A flat file format used to transmit or transport claims, such as the 192-byte UB-92 Institutional EMC format and the 320-byte Professional EMC NSF.

ELECTRONIC REMITTANCE ADVICE

Any of several electronic formats for explaining the payments of health care claims.

EMPLOYER IDENTIFIER

A standard adopted by the Secretary of HHS to identify employers in standard transactions. The IRS' EIN is the adopted standard.


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Term Definition
GROUP HEALTH PLAN

A health plan that provides health coverage to employees, former employees, and their families, and is supported by an employer or employee organization.


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Term Definition
HEALTH CARE CLEARINGHOUSE

A public or private entity that does either of the following (Entities, including but not limited to, billing services, repricing companies, community health management information systems or community health information systems, and "value-added" networks and switches are health care clearinghouses if they perform these functions): 1) Processes or facilitates the processing of information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction; 2) Receives a standard transaction from another entity and processes or facilitates the processing of information into nonstandard format or nonstandard data content for a receiving entity.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996

A Federal law that allows persons to qualify immediately for comparable health insurance coverage when they change their employment relationships. Title II, Subtitle F, of HIPAA gives HHS the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care information. Also known as the Kennedy-Kassebaum Bill, the Kassebaum-Kennedy Bill, K2, or Public Law 104-191.

HEALTH PLAN

An entity that assumes the risk of paying for medical treatments, i.e. uninsured patient, self-insured employer, payer, or HMO.

HEALTHCARE PROVIDER TAXONOMY CODES

An administrative code set that classifies health care providers by type and area of specialization. The code set will be used in certain adopted transactions. (Note: A given provider may have more than one Healthcare Provider Taxonomy Code.)

HYBRID ENTITY

A covered entity whose covered functions are not its primary functions.


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Term Definition
IMPLEMENTATION GUIDE

A document explaining the proper use of a standard for a specific business purpose. The X12N HIPAA IGs are the primary reference documents used by those implementing the associated transactions, and are incorporated into the HIPAA regulations by reference.


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Term Definition
J-CODES

A subset of the HCPCS Level II code set with a high-order value of "J" that has been used to identify certain drugs and other items.


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Term Definition
LOCAL CODES

A generic term for code values that are defined for a State or other local division or for a specific payer. Commonly used to describe HCPCS Level III Codes.


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Term Definition
MAXIMUM DEFINED DATA SET

Under HIPAA, this is all of the required data elements for a particular standard based on a specific implementation specification. An entity creating a transaction is free to include whatever data any receiver might want or need. The recipient is free to ignore any portion of the data that is not needed to conduct their part of the associated business transaction, unless the inessential data is needed for coordination of benefits.

MEDICAL CODE SETS

Codes that characterize a medical condition or treatment. These code sets are usually maintained by professional societies and public health organizations. Compare to administrative code sets.

MEDICARE CONTRACTOR

A Medicare Part A Fiscal Intermediary (institutional), a Medicare Part B Carrier (professional), or a Medicare Durable Medical Equipment Regional Carrier (DMERC)

MEDICARE REMITTANCE ADVICE REMARK CODES

A national administrative code set for providing either claim-level or service-level Medicare-related messages that cannot be expressed with a Claim Adjustment Reason Code. This code set is used in the X12 835 Claim Payment & Remittance Advice transaction.


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Term Definition
NATIONAL COUNCIL FOR PRESCRIPTION DRUG PROGRAMS

An ANSI-accredited group that maintains a number of standard formats for use by the retail pharmacy industry, some of which have been adopted as HIPAA standards.

NATIONAL DRUG CODE

A medical code set maintained by the Food and Drug Administration that contains codes for drugs that are FDA-approved. The Secretary of HHS adopted this code set as the standard for reporting drugs and biologics on standard transactions.

NATIONAL PROVIDER IDENTIFIER (NPI)

The name of the standard unique health identifier for health care providers that was adopted by the Secretary in January 2004.

NATIONAL STANDARD FORMAT

Generically, this applies to any nationally standardized data format, but it is often used in a more limited way to designate the Professional EMC NSF, a 320-byte flat file record format used to submit professional claims.

NCPDP BATCH STANDARD

A NCPDP format for use by low-volume dispensers of pharmaceuticals, such as nursing homes. The Secretary of HHS adopted Version 1.0 of this format as a standard transaction.

NCPDP TELECOMMUNICATION STANDARD

A NCPDP format designed for use by high-volume dispensers of pharmaceuticals, such as retail pharmacies. The Secretary of HHS adopted Version 5.1 of this format as a standard transaction.

NOTICE OF PROPOSED RULEMAKING

A document that describes and explains regulations that the Federal Government proposes to adopt at some future date, and invites interested parties to submit comments related to them. These comments can then be used in developing a final regulation.

NPLANID

A term used by CMS for a proposed standard identifier for health plans. CMS had previously used the terms PayerID and PlanID for the health plan identifier.


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Term Definition
OFFICE FOR CIVIL RIGHTS

This office is part of HHS. Its HIPPA responsibilities include oversight of the privacy requirements.


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Term Definition
PLAN SPONSOR

An entity that sponsors a health plan. This can be an employer, a union, or some other entity.

PRICER OR REPRICER

A person, an organization, or a software package that reviews procedures, diagnoses, fee schedules, and other data and determines the eligible amount for a given health care service or supply. Additional criteria can then be applied to determine the actual allowance, or payment, amount.


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Term Definition
SEGMENT

Under HIPAA, this is a group of related data elements in a transaction.

SELF-INSURED

An individual or organization that assumes the financial risk of paying for health care.

SMALL HEALTH PLAN

Under HIPAA, this is a health plan with annual receipts of $5 million or less.

STRATEGIC NATIONAL IMPLEMENTATION PROCESS

A national WEDI effort for helping the health care industry identify and resolve HIPAA implementation issues.


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Term Definition
THIRD PARTY ADMINISTRATOR

Business associate that performs claims administration and related business functions for a self-insured entity.

TRADING PARTNER

External entity with whom business is conducted, i.e. customer. This relationship can be formalized via a trading partner agreement. (Note: a trading partner of an entity for some purposes, may be a business associate of that same entity for other purposes.)

TRANSACTION

Under HIPAA, this is the exchange of information between two parties to carry out financial or administrative activities related to health care.

TRANSACTION CHANGE REQUEST SYSTEM

A system established under HIPAA for accepting and tracking change requests for any of the adopted HIPAA transaction standards via a single web site. See www.hipaa-dsmo.org.


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Term Definition
UB-92

An electronic format of the CMS-1450 paper claim form that has been in general use since 1993.

UNITED NATIONS RULES FOR ELECTRONIC DATA INTERCHANGE FOR ADMINISTRATION, COMMERCE, AND TRANSPORT

An international EDI format. Interactive X12 transactions use the EDIFACT message syntax.


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Term Definition
VALUE-ADDED NETWORK

A vendor of EDI data communications and translation services.

VIRTUAL PRIVATE NETWORK

A technical strategy for creating secure connections, or tunnels, over the Internet.


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Term Definition
WASHINGTON PUBLISHING COMPANY

The company that publishes the X12N HIPAA Implementation Guides and the X12N HIPAA Data Dictionary. It developed the X12 Data Dictionary, and that hosts the EHNAC STFCS testing program.

WORKFORCE

Under HIPAA, this means employees, volunteers, trainees, and other persons under the direct control of a covered entity, whether or not they are paid by the covered entity. Also see Part II, 45 CFR 160.103.

WORKGROUP FOR ELECTRONIC DATA INTERCHANGE

A health care industry group that has a formal consultative role under the HIPAA legislation (also sponsors SNIP).


*NOTE: An asterisk (*) after a term means that this definition, in whole or in part, is used with permission from Walter Feldesman, ESQ., Dictionary of Eldercare Terminology, Copyright 2000.


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